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http://www.boston.com/yourlife/health/d ... ents_view/

Harvard alters doctors' training

By Liz Kowalczyk, Globe Staff | March 20, 2006

Harvard Medical School is embarking on the most dramatic changes to its curriculum in 20 years, in an effort to better train doctors to understand illness from the patient's perspective and appreciate how patients' lives and the disjointed healthcare system complicate their care.

The biggest shift will occur in the third year, which is the first time that students leave the classroom to see patients. At present, students go from hospital to hospital for one- to three-month stints, a practice that gives them few opportunities to get to know patients or senior doctors.

Under the new curriculum, students will stay in one hospital and follow some patients the entire year.

Senior doctors would be able to better spot students' strengths and weaknesses, and they will hold twice-monthly conferences in which students will discuss not only their patients' medical issues but also ethical dilemmas, family problems, and health insurance snafus.

Harvard will extend the first year by two weeks to give students an introduction to the profession. Students also will be required to take one-semester classes on the effect of social and economic conditions on disease, medical ethics and professionalism, and health policy. These changes, among others, will be phased in over the next three years, starting in August.

For some students, the changes have already begun. Michael Tang is one of 28 students participating in a trial-run of the new third-year curriculum. Tang is at Cambridge Hospital this year, following 115 patients as they go for check-ups, tests, surgeries, and to the emergency room. One is a boy with cancer.

''I really got to see all the complexities of having a disease like cancer -- bouncing from one place to another, and all the logistical and emotional challenges of meeting all these different people and getting bad news from people you don't know," Tang said. ''When I'm a doctor, I'll know that I'm just one piece of the picture and that I have to be aware and working with all those other pieces."

At Harvard's three largest teaching hospitals -- Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, and Massachusetts General Hospital -- third-year students will not follow as many patients throughout the year as students placed at Cambridge Hospital. But the hospitals will implement other measures to enable students to build stronger relationships with their patients and teachers, including appointing a small number of doctors to oversee the students.

Like Harvard, many US medical schools are searching for ways to produce doctors who are more connected to patients and sensitive to the hardships faced by those with long-term illnesses.

The University of Pennsylvania Medical School, for example, now pairs students with a chronically ill patient for three years. The goal is not only to improve doctors' care; studies show that patients who feel good about their interactions with their physicians have a greater probability of following medical advice and returning for follow-up visits.


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--While most medical students eventually work in office practices, they are trained in teaching hospitals, where the pace is frenetic, most patients are in and out in several days, and doctors usually focus on stabilizing very ill patients.

''Most medical students will move into community practices, and they're not at all prepared to do that work," said Dr. Thomas Inui, an associate dean at Indiana University School of Medicine and former head of ambulatory care and prevention at Harvard.

Tang, 26, was shadowing Dr. Dawn Peters at a community health center in Somerville one morning in October when Brian Tipton, then 14, came in with a lump the size of an egg under his left ear. Peters ordered tests and eventually referred Brian to a surgeon at Massachusetts Eye and Ear Infirmary.

Tang joined Brian and his mother, Wendy Codair, when they went to see the surgeon, Dr. Michael Cunningham, on a rainy afternoon in November. His diagnosis was acinic cell carcinoma, a rare cancer.

Codair's mother had died of lung cancer and her father died of colon cancer, and she was frightened that Brian, too, would not survive his disease. She started to cry, and Brian leaned against his mother. Instinctively, Tang took her hand.

''I did it to support her," Tang said later. ''She was really devastated. Just to stand there watching. . . . I don't know."

Tang accompanied the family to at least a dozen appointments, hanging out in waiting rooms, talking to Tipton about his friends, his girlfriend, music, and the ninth grade. He was the first person Brian spoke to after surgery to remove his tumor.

During these hours, Tang saw firsthand the difficulty the family had navigating the healthcare system. Cunningham wanted Brian's medical records from Boston Medical Center and Cambridge Hospital, but Codair had no idea how to get them. Tang took on the job, faxing permission forms to hospitals and records to Cunningham.

Codair, who dropped out of school after the ninth grade, said she often did not understand her son's doctors and was intimidated by them. ''It took me a week to learn how to just say the name of the cancer," she said. Tang often tracked down answers for her and advised her to write down her questions before appointments.

In late January, Brian and his mother went to Mass. Eye and Ear for what they hoped would be his final appointment for a long time. Brian underwent a CT scan to make sure the cancer hadn't grown back. Tang arrived just as Brian was finishing up, and the two hugged and asked about each other's schools.

Brian had an appointment with Cunningham at 3:15 p.m. to get the results of the scan, but when he arrived at the surgeon's office, the receptionist said several patients were ahead of Brian. The waiting room already was overflowing, so the family sat in the lobby with Tang. Every 20 minutes or so, Codair checked on the progress in the office.


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--At 4:25 p.m., the surgeon's assistant led them into an exam room. Cunningham studied scans of Brian's face and neck on a computer screen. ''It looks pretty good," he said.

''Thank God," Codair said. Brian smiled, then stood and hugged his mother tightly.

The family walked out after 5 p.m., exhausted. ''You don't notice this at all on the other side," said Tang, referring to the wait.

The dean of Harvard Medical School, Joseph Martin, who said he believes that observing acutely ill patients only in hospitals ''is a very biased way of looking at medicine," launched the curriculum changes in 2003. He said he was concerned that students were seeing patients as cases when ''it's all about patients as people. We want to create a different mindset."

Martin hired Dr. Malcolm Cox, who led an overhaul of the curriculum at the University of Pennsylvania Medical School, to direct the initiative. He started in part by helping Cambridge Hospital develop the third-year ''clerkship" that Tang enrolled in.

Students not only stay at the hospital and its health centers for the entire year, they do not spend defined blocks of time in the departments of surgery, medicine, obstetrics, pediatrics, neurology, and psychiatry following senior doctors on patient rounds, as is done traditionally. Instead, they meet patients in outpatient clinics and go wherever their illnesses take them.

But many doctors at Harvard's other teaching hospitals considered this approach too radical, and felt Cox was not building a consensus. Cox resigned after 18 months.

''School leadership thought I and the team were going too quickly and in a direction they didn't want," he said in a recent interview. There were also ''deep philosophical differences," he said, with many faculty believing students learn better the traditional way -- immersed in a single specialty for several months.

''You need enough repetition to learn the basic skills," said Richard Schwartzstein, a pulmonologist who is vice president of education at Beth Israel Deaconess. ''Even if they're not your patients, you still get to listen to every patient's hearts and lungs on rounds."

Martin took control of the process, bringing in dozens of physicians to serve on committees, and last summer hired Dr. Jules Dienstag to replace Cox as dean for medical education. The other teaching hospitals decided to make less dramatic changes to their third-year programs; their students still will spend blocks of time in specific departments.

Ethel Delgado, a patient at Cambridge Hospital who has been paired with medical students last year and this year, believes these students will be better doctors than they would have been otherwise. That's an abrupt turnaround for Delgado, 46, who had a heart attack last year and suffers from asthma and a lung disorder.

When she was in labor with her first child, a young man walked into the room. ''I said, 'Are you a doctor?' He said, 'No.' I said, 'Are you an intern?' He said, 'No.' I said, 'You're a student. Out! I don't want anyone experimenting on me!' "

Now, on a slip of paper she keeps in her wallet that lists her allergies and medications, she has also written this message: Page my medical student.

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