How Do You Make a Better Doctor?
For the first time in 20 years, Harvard is reforming the way it molds medical students into doctors. The biggest change is getting them more time with patients in clinics and labs and maybe even house calls.
"Do you have pets?" medical student Angel Foster asks the mother of a 10-year-old patient, probing for what landed the girl in Cambridge Hospital with an asthma attack. No, the mother answers, except for all the mice in the house.
Through the telescope of their conversation, Foster glimpses a world where circumstance conspired with biology to constrict a little girl's airways. It turns out that besides vermin, her young patient has had to endure an older brother's smoking in the four rooms of public housing closeting their family of nine.
A third-year student at Harvard Medical School, Foster is on call at the hospital on this winter night. In the morning, she briefs two of her colleagues in a hospital conference room crowded with the appurtenances of academia (a computer on one shelf) and life on the run (a box of
"If you could talk to your son.... He shouldn't smoke in the house, OK? He could smoke outside, and if he's interested in quitting smoking, there's lots of resources that are around.... What I'd like to do is have a social worker come and talk to you about the housing." Foster says someone also will explain when and how the woman's daughter should take her medicine.
To an observer, it's a rather ordinary scene of a caring doctor in training, one that must play out dozens of times a day at medical schools. But seen through the lenses of Harvard educators, this training Foster is getting is outdated and in need of change, change that is on its way.
For the first time in at least 20 years, Harvard is rewriting its medical school curriculum, essentially redefining the way it teaches doctors to be doctors. The school's goal is to test the reforms in a series of pilot programs and fully implement the revised curriculum in two years. Modernizing the outmoded third-year clerkship is at the top of that list. That's why student guinea pigs will break free from the confines of hospitals beginning this summer and essentially get their own medical practices in an experimental, reimagined clerkship and even -- brace yourself -- make house calls. The goal: to make them better doctors, because in the end, patients are the bottom-line stakeholders in reform, their care the ultimate measure of a bull's-eye or misfire.
Like those carnival tableaux in which people stick their heads into cardboard cutouts of antiquated clothing for a faux daguerreotype, today's medical students are surrounded by relics of a health-care education system that, while not quite as retro as bleeding with leeches, has certainly been stuck in the past.
TWO YEARS IS A DAUNTING DEADLINE BY WHICH TO PIVOT A medical-educational complex with an annual budget not far south of half a billion dollars, 9,000 full-and part-time faculty, 1,300 students, and 18 affiliated hospitals and institutions staffed by world-renowned doctors with sometimes touchy egos. A dozen or so Harvard Medical School work groups, each with more than a dozen members, have sliced areas to be reformed into manageable chunks.
It's a surprising confession of fault. Isn't American medicine the best in the world, and isn't Harvard one of the foremost teachers in American medicine? That conventional wisdom papers over some very unpleasant facts. Health care's crazy aunt in the attic is its error rate. Dr. Malcolm Cox, dean of medical education at Harvard Medical School, notes that the Institute of Medicine of The National Academies, an independent advisory group to the federal government, reports that up to 98,000 Americans die each year from preventable mistakes by health-care providers. The institute blames a mind-numbing labyrinth of care in which patients are handed off like batons -- and the one doing the handing off rarely looks back.
"When patients see multiple providers in different settings, none of whom have access to complete information, it is easier for something to go wrong than when care is better coordinated," said a 1999 institute report. "At the same time, the provision of care to patients by a collection of loosely affiliated organizations and providers makes it difficult to implement improved clinical information systems capable of providing timely access to complete patient information."
That's not all. According to a study by the nonprofit think tank The Rand Corporation that The New England Journal of Medicine published last year, patients nationwide receive little more than half of recommended care, based on professional standards.
Against that backdrop, the warts of the current medical-school clerkship tower like mountains in the eyes of Harvard educators. Start with the abbreviated length of duty. At most medical schools, students-rotate in and out of a series of mandatory clerkships in different specialties, most lasting no more than a few months. Angel Foster will never see her young asthma patient outside of the hospital, and probably never again. She and her fellow students "learned how to manage an acute asthma flare," reflects Bernstein, their instructor. But "they didn't learn how to manage the asthma patient when he comes back and says, 'I'm still coughing every night.'... You don't put those [patients] back in the hospital. You adjust their medicines and add on different medicines."
Foster and her peers just don't spend enough time with their patients, Harvard's leaders say. And they don't spend enough time with experienced teachers. And they spend all of their time inside a hospital. But many sick people don't, at least not anymore. Harvard is betting that its reforms can make better doctors out of its students, and when Harvard gets a notion like that, the rest of the field perks up. Veteran professor Dr. Ronald A. Arky and other planners lured seed money for the new clerkship from groups like the Association of American Medical Colleges. In 40 years at Harvard, Arky has heard more than his share of brilliant reform ideas and says many weren't as far-reaching as they were cracked up to be. But "many people... outside of Boston are going to be watching us on this one," he says. As well they should. Ask Malcolm Cox why the way in which medical students are taught needs to change, and he'll cite the institute report: What doctors don't know could kill you.
THE BASIC MATH OF MEDICAL SCHOOL -- TWO YEARS IN CLASS plus two years in hospitals equals a good education -- is fuzzy to begin with. By the time students hit the corridors, it's easy for them to have forgotten some of the classroom science they learned their first two years. It also turns out that hospitals aren't always the best places to learn about sick people. Managed care and medical advances mean fewer patients are admitted to hospitals, and for those who are, the stays are shorter. Most of us get our care in doctors' offices, neighborhood clinics, nursing homes, even our own homes.
"The schoolhouse in which we train physicians" -- the hospital -- "has changed dramatically in the last 10, 12 years," says Arky. "We were slow in appreciating the fast turnover of patients, the fact that patients, to get through the door, have to be very, very sick.... We throw students who are just off the training wheels into the expressway."
Moreover, 35 grand a year in tuition and fees buys less face time with that hot-shot faculty than you'd think. Residents, themselves newly minted MDs, do most teaching in hospitals. Doctors at Harvard Medical School's affiliated hospitals who are on the faculty (not all the physicians are; you have to apply for an appointment) are expected to teach 50 hours a year as junior faculty and 100 hours as senior members, but only if asked. But doctors earn their grocery money from treating patients at the hospitals or through their private practices. The school's teaching stipends are puny in comparison and often zero, the school's real currency being the patients the Harvard affiliation draws to its doctors' private practices, or research grants that the Harvard affiliation funnels doctors' way. The downside is that some experienced doctors on the faculty thumb their noses at teaching requests, while others teach more than their share, for little reward or recognition.
No one demeans residents' essential contributions. Nor is every faculty genius cut out for the classroom. Yet when you consider that these students could someday be standing over you in the operating room with your life in their hands, having seasoned doctors teach them is a no-brainer. Student Walter Bethune found Bernstein's basic science refresher on asthma an invaluable update on what Bethune had been taught in his first two years of medical school. "That doesn't happen all the time," he says.
That teachers can hibernate in their labs and offices is the result of a historic evolution at medical schools that reached its pinnacle in Boston. After all, it was the lab, not the classroom, that made Harvard Harvard. By the 1930s, Harvard Medical School had leapfrogged the competition in prestige, "largely because of its unparalleled laboratory and clinical resources and its phenomenal record of accomplishment in medical research," physician/historian Kenneth M. Ludmerer wrote in his 1999 book about medical education, Time to Heal. But what really wilted the teacher's role, he wrote, was the passage of Medicare and Medicaid. Lyndon B. Johnson's Great Society achieved the indisputable good of giving medical care to the elderly and poor, including at academic medical centers. But that tide of new patients further eroded the time that doctors had for their students.
The bottom line for many doctors has been the devaluation of teaching in medical schools. "I don't think I truly exist as far as Harvard is concerned," Bernstein says. That's not a universal sentiment among teachers. But worries about teaching's rewards and status spurred the creation three years ago of The Academy at Harvard Medical School, which plucks outstanding teachers from the faculty to mentor colleagues and develop innovative projects to improve teaching. Now it's the engine of the coming reforms.
FINAL DECISIONS REMAIN to be made about reform specifics, but the broad compass points are clear. Several new programs seem to attack problems cited by the Institute of Medicine study and the New England Journal of Medicine. An overly complicated medical system? Well, notes Cox, the dean of medical education, Harvard Medical School is part of a university that's home to exemplary business and engineering schools with expertise in organizing complex systems. The medical school is teaming up with the former to offer a joint MD/MBA to teach doctors how to better manage that system.
Haphazard adherence to care standards? Population science -- augmenting the study of the body with the study of medicine's effects on vast numbers of people -- should make a difference. Cox offers an example: An old class of drugs for treating heart and kidney disease and hypertension sometimes has the side effect of raising blood potassium -- a bad thing. Newer drugs for the same ailments should elevate potassium as well. But they don't, a fact confirmed by broad-based population studies. Armed with that knowledge, a doctor could better tailor which drugs she'd prescribe to which patients. Cox expects beefed-up courses on population science in the new curriculum.
But being a good doctor takes more than scientific knowledge or management skills; it takes empathy, the gift of understanding a patient and his or her life. The medical school recently began a joint MD/PhD in social sciences, including sociology and psychology. Cox reasons that it will help focus students on nonmedical issues that are vital to their work, from familiarizing themselves with patients' care wishes to the issue of the millions of Americans without health insurance. To the extent doctors have lost that focus, says Cox, "What we may have lost as a profession is part of our soul."
Similar efforts can be found at other medical schools, which are also tinkering with the hoary clerkship. But there are uniquely crimson fingerprints on the combination of changes that Harvard plans for the potentially revolutionary clerkship it will launch this summer.
A pilot program to start in July will allow eight medical students to replace the traditional third-year clerkships with a yearlong one, treating patients across the spectrum of their illnesses and the span of their care. The students will be based at two Cambridge hospitals but not confined there; they'll see their patients in doctors' offices, the community clinic, the rehab center, wherever the patient needs to go -- even in their homes. For students, "the plan is to make sure that they see the whole illness," from onset through diagnosis through treatment, says Dr. Barbara Ogur, a co-director of the new program. And they'll be supervised by experienced doctor-teachers. Ogur and co-director Dr. David Hirsh hope to find funding to compensate participating doctors for teaching.
"If Harvard is successful," predicts Dr. Michael E. Whitcomb, senior vice president for medical education at the Association of American Medical Colleges, "it could be influential on schools around the country." Students are as intrigued as Whitcomb. Angel Foster felt that the existing clerkship allowed her to bond with her young asthma patient, but "I am not in a position to follow up with this patient after she leaves the hospital," she says by e-mail. The new clerkship "would have allowed me to better understand the realities of asthma and the challenges to preventing" attacks. New clerkships, she says, might "expand learning opportunities to medical students and resources to the patients we follow."
Whether the new clerkship ultimately will replace the old system is undetermined. "What I am sure about is that we will not leave the existing clerkships exactly as they are," insists Dr. George E. Thibault, director of The Academy at Harvard Medical School. Another certainty is that transfiguring Harvard Medical School's education will proceed hand in surgical glove with a review of teacher pay. "We will not have a better educational process, regardless of what design of the curriculum we come up with," Thibault argues, "if we do not address the issue of faculty compensation [and] helping faculty become better teachers."
"HARVARD ENDS LETHAL Medical Goofs, Insures the Uninsured, Saves the World." It would be nice if such a headline were the end of the story. Yet the best teacher of all -- experience -- suggests that reform is a Mobius strip, following upon itself into seeming infinity. Curriculum upgrades at Harvard Medical School in 1957, 1965, and 1968 all took stabs at weaving the science instruction of med school's first two years with the clinical training of its second two. Harvard's last major reform 20 years ago, called the New Pathway, replaced big lectures with smaller tutorial groups so that students could better tap the talents of that big-name faculty. For all these earlier efforts' successes, deficiencies remain as issues for today's reformers.
"All of the things we're talking about have been continually tried," concedes Arky. "Each time we try it, you move it a little along." Upending the traditional clerkship may be different, though.
The New Pathway focused on the first two, pre-clinical years of med school. The pilot clerkship addresses deficiencies in the hands-on training that occurs during the last two years of school. Moreover, it stresses basic principles of good care across the spectrum, while traditional clerkships pigeonhole students by individual disciplines. It's a "return to the future," Arky says, an attempt to recapture the ethos of the days before medicine splintered into specialties.
"New Pathway was an important program," says Ludmerer, the historian. "But this perhaps exceeds it."
The critical difference is the attention being paid this time around to the sick. This past winter, planners of the new clerkship ran their big idea by a focus group of patients, several of whom worried that the medical students assigned to shadow them in the new, longer clerkship might be burdened with too many patients.
One of those patients, LaVerne Jefferson, says that, as it was explained to her, a medical student in the new clerkship "would pretty much be your primary physician." Jefferson, who gets treatment for her diabetes, hypertension, and back pain from the Harvard-affiliated Windsor Street Health Center in Cambridge, says she's unable to work because of her condition and needs reliably available care: "If they have 10 patients they're going to be seeing through that year's time, I think it would be kind of impossible for them to be with me when I go for my appointments." Planners promised her they would guard against overloading the students, she says.
"I'LL SHOW YOU THE FUTURE," says Dr. John D. Halamka, chief information officer at Harvard Medical School. He is neither ubergeek (he climbs mountains for fun and is married to an artist) nor messianic futurist. As cochairman of the working group on technology in the reforms, he has to summon the future, or at least figure out how to harness its high-tech tools to educate doctors. Students in the new clerkship, for example, will record their cases on personal digital assistants, or PDAs. That will enable supervisors to pair the students with patients suffering an ailment that they haven't yet encountered, says Halamka.
Harvard's reformers contemplate even more artful blending of technology and education. For a case study, meet Mr. White. Balding and bespectacled, the retired carpenter is frankly a jowly grouch, his face seemingly freeze-dried in frown mode. His wife browbeat him into visiting his doctor to have his nagging cough checked, and he's resentfully gruff. "So I hear you have a cough," says Dr. Grace Huang. "Yes, I have had a cough for two months now," comes the answer. "You know, not everyone can just stand around all day long and look busy. I have things to do."
Mr. White is a patient of the future: a virtual patient, played by an actor in still photos and streaming video across Huang's computer monitor. Huang, an instructor at Harvard and an internist at Beth Israel Deaconess Medical Center, typed her question on her keyboard to demonstrate the teaching tool. Mr. White's answer came back as text flashed on the screen, triggered by the computer having recognized key words in the question. Harvard students may "talk" with, "examine," and "treat" Mr. White and 17 other virtual patients. Believe it or not, coping with a computer with a bad attitude can be educational. Fewer hospitalizations and shorter stays mean clerkship students see fewer varieties of illness in the hospital setting. Recently, a student who had just wrapped up a clerkship told Huang, a member of Halamka's technology committee, that she'd never seen a pneumonia case. This stunned Huang, since pneumonia and influenza are grouped as the seventh leading cause of death in the United States.
Virtual patients, with everything from diabetes to lung cancer, expose students to illnesses they've perhaps missed in real patients. The computer guides students, alerting them if their questions are irrelevant given the symptoms or if they botched the diagnosis. Tell the virtual guy with chest pain that his problem isn't serious, and the computer informs you that he died the next day. (One advantage of technology: You can't really kill the patient.)
For now, virtual patients are elective study at Harvard Medical School. Research to be done this year will assign obstetrics students to virtual patients to see if the technology sharpens their skills beyond those of their peers. A similar experiment at the school will test the usefulness of robotic-patient simulators. These would truly set Steven Spielberg's heart aflutter: robot mannequins that breathe, have a pulse, and talk (via the Wizard of Oz trick of a doctor behind a curtain voicing the mannequin). Now in limited use to practice communicating with and diagnosing patients, the mannequins may be recommended by the technology group for more extensive use in Harvard's new curriculum.
Modern medical knowledge vastly exceeds any single person's capacity to learn it. Fortunately, the Internet puts warehouses of information a mouse click away. Therein lies the way to add curriculum requirements without frying student brains.
Since 2001, notes for every lecture by every faculty member in every course at Harvard Medical School have been put online. The school is now recording every core lecture on streaming video and making it available online within an hour of its delivery. Students can also type in a single-word search and have the computer call up lecture transcripts in which that word was uttered, indexed by date, course, professor, and time delivered. So what's to stop a student from cutting every class and getting it all off the computer? "Harvard medical students are very compulsive," says Halamka. "They're always there."
As new ways of teaching become available, they elbow aside old ones. Malcolm Cox notes that students today spend far fewer hours dissecting cadavers than when he attended Harvard in the 1960s. Someday, he muses, virtual cadavers might offer such precise anatomical clarity that they'll replace dissection time altogether.
Or would they? Anyone who aspires to be a doctor must overcome the natural human aversion to being near a dead person and cutting into a dead body. Working with deceased fellow creatures inspires a certain humanity. "You want the student to develop respect for the body and respect for the human being that was embodied therein," says Dr. Mitchell T. Rabkin, a professor of medicine at Harvard Medical School. It's the difference between a Dr. Romano, the surgeon character recently killed off on TV's ER, and that show's Dr. Carter. Romano was a lizard, technically proficient but cold-blooded. Carter is the compassionate healer we all want at our bedsides.
Technology can help make a Dr. Romano. It will never carry a student to the level of Dr. Carter. That takes a lesson from Hippocrates, whose oath says medicine's noble work is to treat the human body. But as Harvard moves forward, it would behoove its leaders to remember that even the world's smartest doctors must, above all else, hold on to their souls.
Rich Barlow is a freelance writer living in Cambridge.