ON A WEDNESDAY IN DECEMBER 2008, a young man came into student health services with a dripping nose, a scratchy throat – and an agenda. A Harvard sophomore deep into finals, he just wanted an antibiotic to make his cold go away. His boyfriend had been prescribed one a week ago and had been back to normal in days. As a third-year medical student, I had my own agenda. I had learned that antibiotics wouldn’t cure his viral infection, had potential side effects, would waste health care dollars, and would probably help breed drug-resistant bugs. But all of this information was useless unless I could persuade this determined, pink-faced young man I’d met minutes ago that I was right and he was wrong.
For many prospective medical students, the promise of someday taking care of patients pushes us through dry requirements like organic chemistry and the MCATs. On my own application to medical school, I had fervently written that I couldn’t wait to make “resources and knowledge available to my patients, allowing them an active role in the healing process.” As Harvard medical sociologist Dr. Nicholas Christakis puts it, we enter “starry-eyed and altruistic.” But experts have found that after only a few years of training, those attitudes seem to slip away. There I was, halfway through my first clinical year of medical school, tripping over my words and feeling the urge to head-butt my patient into agreement.
This phenomenon has real implications for the quality of American health care. Patient-centered care, a decades-old concept that has reemerged in the national health care debate, is not necessarily about giving patients what they want (I’m holding firm on the antibiotics). It’s about putting them first: delivering safe, effective care that addresses both their needs and their preferences. Many studies have connected aspects of patient-centered care, like strong patient-doctor relationships and effective communication, to improved outcomes and even lowered costs. About as many studies suggest that doctors aren’t so good at this.
For most of medical school history, topics like ethics, professionalism, and the doctor-patient relationship were not covered formally, left instead to be addressed by chance. This changed in the mid-’80s through the introduction of courses like Harvard’s Patient Doctor. In my first year of training, in 2006, five classmates and I would visit Beth Israel Deaconess Medical Center on Wednesday afternoons to meet with patients who, out of altruism or boredom, had agreed to let us practice our interviewing skills on them. We learned what to ask first and how to show empathy. But after two years, we transitioned into working in the hospital full time. Schedules were tight. Our focus on connecting with patients faded as we scrambled to fit in and observed the way things were really done.
Dr. Edward Hundert, a senior lecturer on ethics at Harvard Medical School, says that when first-year students answer tough questions about the ethics of end-of-life care or patient-doctor confidentiality, they usually present two points of view: as a person and as a doctor. As part of a study in the mid-’90s, Hundert asked students to tape-record these and other on-the-job conversations, and he played their answers back to them later in their training. He found that the students couldn’t imagine ever having made this “naive” person-or-doctor distinction. This process, he says, is called “professionalization’’ (by those who embrace it) or “socialization into medicine’’ (by those who do not). One ongoing challenge for medical educators has been to preserve that focus on the patient.
In 2008, in an effort to address this, Harvard changed its traditional third-year programs at Brigham and Women’s Hospital, Massachusetts General Hospital, and Beth Israel. The year is still divided into clerkships that focus on one discipline, such as surgery or pediatrics, but since 2008, students have been assigned to a single hospital for the year and work alongside a doctor at a primary-care clinic once a week. Even so, this is no guarantee students will see most patients more than once. However, there is another program at Harvard that has been doing things differently for several years now. It’s an idea that takes patient-centered care to another level.
CAMBRIDGE HOSPITAL is a seven-story tan brick building in Cambridge. This is a neighborhood institution, part of the Cambridge Health Alliance and the sort of place where “Twinkle, Twinkle Little Star” is broadcast hospital-wide whenever the maternity ward has a new delivery. The Cambridge Integrated Clerkship was launched in 2004, and each year there have been a dozen spots for Harvard Medical students. Each student gets his or her own panel of patients designed to reflect the spectrum of medical conditions that affect most Americans. Under the supervision of senior doctors, students follow these patients through inpatient stays and outpatient appointments. The students get to see the progression of chronic illnesses and the outcomes of clinical decisions, and they gain a rare view of the health care system, seeing where it works – and where it falls short.
To find out more, I visited the Cambridge clerkship students for lunch on a chilly Thursday afternoon last December. It’s 1:20 p.m., and three beepers go off in unison. Nate Favini checks his and lets out a groan. The patient he helped admit on Tuesday is back in the Emergency Department with dangerously high blood pressure. She had been discharged from the hospital and scheduled to have an outpatient ultrasound of her kidneys. If only his patient had gotten the tests she needed earlier, Nate says, shaking his head. “We see how people with complex illnesses keep bouncing around, how they experience fragmentation” of services. And the Cambridge system, with its electronic health records and focus on frequent communication between providers, is better than most, he says.
Kelsey Leonardsmith also says she has developed a more realistic view of health care. “When I first rotated through an inpatient psych ward, I was impressed by how much better patients got after a week,” she says. “Then I got to my outpatient experiences, and I’d see them coming back to the hospital so many times.”
In February, I accompany another student, Simeon “Sim” Kimmel, to visit Guzel Bikyanova, a student from Russia who was about to deliver her first child. She and Kimmel were introduced at her first appointment with her obstetrician, who asked her whether she’d mind having a student there. “I said, ‘Yes, I am OK with this.’ After that, he started following me everywhere.” They both laugh. “In a good way.”
It’s nice to have someone to help explain things, she says. “He is learning something, and I am taking benefit from that, too.”
Their supervisors say these students improve care by navigating patients through the health care system, acting as their advocates. David Hirsh, cofounder and co-director of the Cambridge Integrated Clerkship, contends the program may even help preserve students’ empathy. In a 2007 Academic Medicine study, he found that students improved their previous scores on humanism and professionalism tests after completing the program, while those in more traditional programs did not. Some worry that students miss out on what the more research-oriented Harvard teaching hospitals have to offer. But studies by Hirsh and his colleagues show that on tests of clinical knowledge, Cambridge clerkship participants perform as well or better than those in the traditional curriculum.
THOUGH THE CAMBRIDGE MODEL has not caught on in the other Harvard hospitals, medical educators elsewhere are taking notice: The program was featured in last year’s Carnegie Foundation for the Advancement of Teaching’s report on reforming medical education, and it is being adopted by several dozen medical schools around the world.
But there are drawbacks, too, some experts say. “My concern is that the pendulum may be swinging too much the other way,” says Dr. Paul Hemmer, a professor of medicine at Uniformed Services University of the Health Sciences in Bethesda, Maryland. The advantage of programs like Cambridge’s is that students gain a sense of “ownership” of their patients, he says, but they can get that in more traditional settings, where they play a larger role when their patients are hospitalized. “I worry that it devalues what can be gained being involved in acute care in the hospital, working in a team, [and] coordinating across services.”
Kimmel, a Columbia graduate and MD/PhD candidate in anthropology, concedes this point. “We see how patients come in and out of the hospital, but it’s harder to understand some workings of the hospital – for example, why people are discharged.”
But, to him, the trade-offs have been well worth it. When I met with him last, he had logged nearly 300 patients on his roster but counted 25 as “his” – patients he’s seen at least five times each. He’s had a closeness with his patients that has been harder for me to match. He tells me about one: a 92-year-old man with advanced Alzheimer’s who had told his daughter he did not want extensive medical measures to keep him alive. Kimmel followed him over several hospital admissions and even visited him at home. Each time the man came to the hospital, the medical team would talk to his daughter about his wish not to be resuscitated or intubated. But every time, she would change her mind and ask for feeding tubes and intravenous antibiotics.
Kimmel was at a Fourth of July barbecue when he got a call that the man was in intensive care. When he arrived, the daughter was asking for aggressive care. He helped persuade the daughter to place her father on comfort measures only. When the man died, the team asked Kimmel to notify the family, and the daughter invited him to the funeral. He went. He couldn’t imagine it any other way.