Palm Beach Medical College

Early Patient Contact in Medical Education
Monday, May 25, 2009

Palm Beach Medical College educational model based in early patient contact, is also used in several of the new US medical schools as this article in The Chronicle of Higher Education is reporting.

Some of the advantages are listed here. Perhaps the more important benefits are that it makes the early teaching of basic sciences much more relevant, and that facilitates the development of problem oriented teaching curricula.

McMaster University Medical School in Canada and Nottingham University Medical School in the United Kingdom were early pioneers of these methodologies in the 1970's. However it has taken more than 30 years , and new medical education schools , without the restrains of history, for this methodology to be accepted by the medical education community

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From the issue dated May 22, 2009

New Medical Schools Pair Students With Patients From the Start

By KATHERINE MANGAN

When Lawrence G. Smith was tapped to help create a new medical school on Long Island, the last thing he wanted was a traditional model in which students had to wait until their third year of training to have any meaningful interaction with patients. Dr. Smith, the chief medical officer of a 15-hospital health system, instead favored approaches like sending first-year students out with ambulance crews and encouraging future doctors to develop long-term relationships with patients.

Otherwise, he says, "you're two years into medical school and $100,000 in debt, and you're about as useful as a Boy Scout at a family picnic."

Dr. Smith is the founding dean of Hofstra University School of Medicine, one of nine new allopathic medical schools, which are in various stages of seeking full accreditation. (Four of the schools, which graduate doctors with M.D. degrees, have already received preliminary accreditation.)

Unlike the schools of old, where students spent two years focused on science and theory before they set foot in a hospital, these new schools are integrating clinical care into the first two years.

Existing schools have taken steps in this direction. But, says John E. Prescott, chief academic officer of the Association of American Medical Colleges, "the new schools are moving the bar farther and faster in coming up with innovative ways to provide important clinical experiences early in medical education."

At least two new osteopathic medical schools, which graduate Doctors of Osteopathy and emphasize holistic approaches and hands-on manipulation, are also seeking accreditation for programs that include early clinical experience.

One reason that established medical schools have moved slowly is that course work in the first two years tends to be so demanding that faculty members are often reluctant to introduce clinical requirements that would take away from classroom time.

That mind-set is loosening as new schools open in response to warnings from both the medical colleges' association and the American Medical Association about a looming shortage of physicians.

Following is a look at new or proposed schools at Hofstra, Florida International, and Rocky Vista Universities and how they are reconsidering the way physicians should be trained:

Hofstra U. School of Medicine

The Long Island medical school is pursuing preliminary accreditation and hopes to open in the fall of 2011 with an inaugural class of around 40 students.

The school's dean, Dr. Smith, will also continue his job as chief medical officer of the North Shore-Long Island Jewish Health System, which will be a partner with the medical school.

Being part of a sprawling medical system with services like a 60-vehicle ambulance fleet will give first-year students early exposure to patients in various settings. The school plans to assign first-year and possibly second-year students to ambulance crews, where they will work with emergency medical technicians and learn some basic EMT skills.

"Working on our ambulance crews will give students an opportunity to literally pick up patients in their own homes, which is a powerful way to start a relationship," says Dr. Smith.

Students will also be assigned to individual patients, to track their progress over a period of months or even years. A student who went with an ambulance crew to the home of an elderly woman who fell and broke her hip might follow that patient's progress over the next few years as she was treated in a hospital, rehabilitated in an outpatient clinic, and moved by her family into a nursing home.

Dr. Smith concedes that having 40 students tracking 40 patients as they make their way through the maze of health-care providers could be a "logistical nightmare," so the school will rely heavily on students' initiative to make it work. It is a bit of a risk, but he believes that students will welcome the challenge.

Students will probably spend one day a week in the system's hospitals from the beginning of the first year, with close monitoring by mentors gradually giving way to more independent interactions with patients.

"The show-and-tell method of education doesn't work with people old enough to be in medical school," says Dr. Smith.

When students are studying geriatrics, they could spend time in one of the system's nursing homes, and when the topic is the gastrointestinal tract, they might observe patients with conditions like Crohn's disease.

The curriculum is being developed by David L. Battinelli, associate dean for education. He moved to Hofstra from Boston University, where he had been a professor and vice chair of the department of medicine.

"Many schools have rotations of six to eight weeks. We're looking at rotations that could be years in length," he says. Those rotations, in which students will follow a physician, will occur in the first two years, before the shorter, specialized rotations that upper-level medical students usually experience.

In planning the curriculum, administrators solicited advice from older physicians who had begun their practices at a time when a physician followed a patient through her pregnancy and delivery and then treated the mother and baby for years afterward. "People who did that remember the names of their patients," Dr. Battinelli says. "It's one of the most vivid experiences a doctor can have, and it's dropped away."

Dr. Battinelli says the school has received support from its accreditor, the Liaison Committee on Medical Education, in its efforts to shake up the typical medical-school curriculum. "They want you to reassure them that you won't be out of business in a year, but they're encouraging us to be daring."

Florida International University College of Medicine

Approved by the state in 2006 and granted preliminary accreditation two years later, the Miami medical school will accept its first students this fall. A major feature of the new curriculum will be its NeighborhoodHELP program, which will send interdisciplinary student teams from the university's medical, nursing, social work, and public-health programs into some of South Florida's poorest neighborhoods to learn from and help struggling families.

The medical school's founding dean, John A. Rock, predicts that by improving access to education, preventive care, and research, the program could save the state millions of dollars in health-care costs by 2020. If, for example, students can explain to women that taking folic-acid supplements while pregnant can reduce the chances of their babies being born with spina bifida, a crippling disorder of the spinal cord, the number of cases could drop, he says. And if students can identify people with diabetes and get treatment to them, fewer patients might show up in local emergency rooms with complications such as heart disease or nerve damage.

The 43 students in the inaugural medical class will be divided into four teams. Each team will focus on a predominantly Hispanic, African-American, Caribbean, or Jewish neighborhood and will work with students from other professional programs, all supervised by a faculty member.

During the first half of their first year, students will pursue topics including biostatistics, epidemiology, and culture in the context of their assigned neighborhoods.

Then, in the spring, each medical student will be assigned to a family whom he or she will visit in their home a couple of times a month. That relationship will extend through the remaining three years of medical school. Students will work with the families' physicians and refer family members to health and social services in the community.

"The households become faculty members, part of our teaching," says Dr. Rock. "It will be an important experience for our students to understand the difficulties families have navigating the health-care system in our country."

Following a family over more than three years, students will be able to witness the progression of diseases and other medical conditions in a way that a teaching hospital, with its rapid patient turnover, does not allow.

Students whose training is limited to teaching hospitals also tend to see patients at their sickest, but not as they struggle with the day-to-day challenges of living with chronic problems such as diabetes or kidney disease. By meeting these patients when they are relatively healthy, students can learn how to teach preventive care. Four times a year, the teams will get together to discuss and document the unique characteristics of their neighborhoods' cultures and health-care needs.

Among the school's high-profile faculty recruits is Joe Leigh Simpson, executive associate dean of academic affairs. Dr. Simpson came from Baylor College of Medicine, where he served as chair of obstetrics and gynecology. His duties at Florida International include hiring faculty members and overseeing the accreditation process and curriculum development. He says he was attracted by the chance to "start with a clean slate."

Deans of other medical schools had tried to recruit him from Baylor before, he says. But established institutions have too many obstacles to change. "It's always an issue not of what you can do, but of what you can't do," he says. "There are so many sacred cows you have to maneuver your way around in order to get anything done."

Starting from scratch, he and his team collapsed the usual six basic-science departments to four. "Where there were artificial distinctions, we saw opportunities to mix and blend in a way that makes sense."

Other medical schools have been consolidating basic-science departments into fewer distinct units, and some have gone so far as to create a single department of basic sciences. But new schools can do so without encountering resistance from professors whose careers, and professional reputations, have been tied to their departments.

The new faculty members "like the pioneering spirit and being able to help write the rules," says Dr. Rock.

Rocky Vista U. College of Osteopathic Medicine

The provisionally accredited school in Parker, Colo., opened this academic year with an inaugural class of 152 students.

Every student is required to perform community service in a domestic-violence shelter, drug-and-alcohol-treatment center, migrant-worker clinic, or other public-health facility. That experience is meant to enrich their yearlong firstand second-year courses in clinical and community medicine.

The school's dean, Ronnie B. Martin, says this approach bolsters the sense of altruism students have when they enter medical school.

"Medical school, with its 18-hour days and constant studying for tests, will beat that right out of you, and putting students in those service centers is critical," he says.

Camille Z. Bentley, the school's chair of community and rural medicine, agrees. "This is what motivates them and keeps them going in the rough times of medical school," she says. This is the carrot we dangle in front of them that they get to nibble at from time to time."

Students who help out at a migrant health center might give physical examinations, under a faculty member's supervision, to day laborers who suffer from back pain after long days of farming or building houses. The exam might include muscle-energy technique, a treatment that relies on moving or massaging muscles and bones to relax muscle spasms.

Courses are aligned, whenever possible, so that anatomy students are studying the same body parts that they are handling in a course on manipulation techniques.

"Change is so much easier at a new school," says Walter R. Buck, chair of structural medicine at Rocky Vista. "You don't have to convince this committee or that and fight 50 years of tradition."

The newer schools seem, in fact, to be establishing some traditions of their own based on these new ideas. Dr. Prescott, of the medical-colleges' association, says their leaders have been meeting and sharing ideas on how to structure firstand second-year curricula in ways that allow students to practice what they are learning.

"More and more are realizing the value of having students exposed to clinical situations early and often."

Section: The Faculty Volume 55, Issue 37, Page A1

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