REINVENTING THE THIRD-YEAR MEDICAL STUDENT

A year ahead in medical school, my friend had been a constant source of support and inspiration, offering study tips for courses and warnings about professors and, when he had neither, hilarious spot-on imitations of classmates and teachers. Patients he was beginning to see in his introductory course on the physical exam seemed to adore him, too; a few even wanted to set him up with their daughters.

“When we’re done with medical school and residency,” he always said, “we’ll be the doctors we’ve always dreamed of being.”

He stopped saying that during his third year of medical school.

One evening that year, I ran into him in the hospital cafeteria. The third-year schedule of rotating every few weeks among teams of doctors, trainees and real patients had left him gaunt. He showed me a stack of index cards, one for each patient he had been assigned in the last week.

“I got an ‘appy,’ a gallbladder and a breast biopsy,” he said, referring to patients with appendicitis, a gallbladder infection and breast cancer. He pulled out one card highlighted in yellow and smiled. “I also got a Whipple,” he said, referring to a patient with pancreatic cancer who needed that potentially complicated surgery.

“That,” he continued without flinching, “was awesome.”

My friend wasn’t the same. The patients had been reduced to their diseases.

For nearly a century, the third year of medical school has been a pivotal point in training, a crucial step in the development of professional skills and attitudes toward patients. Recently, however, the tradition of monthlong “rotations” – a speed-dating introduction to the major disciplines of medicine and the issues patients face – has come under fire.

During their third year, medical students are under constant pressure to perform for an ever-changing group of senior physicians, who in turn must evaluate the students based on brief interactions. Sailing through as many as six disciplines in just under a year, students have opportunities for only transient relationships, garnering mere snapshots of their patients’ illnesses and lives.

Not surprisingly, studies have shown that these experiences result in “ethical erosion.” Students’ sense of empathy and bedside manner deteriorate, and many begin to refer to their patients not as people but as diseases, that dehumanizing shorthand of the wards.

Now a growing number of educators are working to reinvent the crucial third year of medical school. A recent article in the journal Academic Medicine explains how one program has successfully eliminated traditional block rotations, promoting instead yearlong relationships between students and their patients and capitalizing on the patient-centered values and humanistic impulses that led the students to medicine in the first place.

Since 2004, the Harvard Medical School-Cambridge Integrated Clerkship has assigned every third-year medical student to a “panel” of up to 100 patients to care for over the course of the year. Students see their patients in the clinics of the Cambridge Health Alliance health system where the program is based, but also follow and assist with any outside consultations, admissions to the hospital, operations and even home visits. During the year, students are also required to shadow several assigned preceptors, senior physicians from the major specialties, in their clinics every week.

After offering this innovative third-year program for a few years, the organizers assessed the skills and experiences of the first students. They found that these students had more rewarding and humanizing learning experiences than their peers on traditional block rotations. And the positive effects continued to influence the students’ work even after they returned to the traditional track for the fourth year of medical school.

On standardized exams of knowledge and skills, most students from the new track performed as well as or better than traditional students, and many felt better prepared for clinical practice. On tests assessing important elements of care, these students were also better prepared to involve patients and their families in decisions, act in a caring way and deal with ethical issues.

“Our goal was to use the students’ idealism and altruism as a frame for their learning and mastery of the science,” said Dr. David Hirsh, lead author of the study and director and co-founder of the innovative program.

Some students followed their patients’ entire pregnancy and childbirth, then helped care for the baby. Other students were present for the entire course of a patient’s terminal illness, later becoming key figures in helping the family deal with that person’s death. One student who witnessed her patient being given a cancer diagnosis remained at that patient’s side through multiple complications that arose from treatment; the patient later attributed her survival to the constant and reassuring presence of herstudent.

“Patients have gone on to tell their friends about the program,” Dr. Hirsh said. “Now we are having difficulty keeping up with patient requests for their own medical student.”

The program also raises some significant challenges for educators and students. The commitment and level of guidance for senior physician preceptors is longer and more involved than usual. And students must deal with the intricacies of intense patient relationships, learning to set and communicate appropriate boundaries with patients.

Nevertheless, this program’s early successes add to what Dr. Hirsh calls a“growing movement” in medical education. Medical schools at Columbia University, the University of Minnesota, the University of California, San Francisco, and Harvard are strengthening their innovative programs, and more schools in the United States and abroad are poised to start similar ones. Dr. Hirsh and his colleagues are also examining how their approach influences student attitudes and skills years later, after graduation and during residency. The initial findings appear promising and may fuel further interest in this work.

“Good enough or even great enough can’t be our standard,” Dr. Hirsh said. “We need to allow medical students to be their fullest selves and to support their highest ideals of patient care.”

Janie Guice is the recruiter for the Mississippi Rural Physician Scholarship Program.  Listen to her story on NPR’s Morning Edition.

When Janie Guice looks at the Mississippi Delta she sees a vast, flat flood plain home to cotton fields and catfish farms. She also sees desperate rural health problems and a deep shortage of doctors to offer care. Her job: to find doctors to fill that void.

“Who is the one that is going to go back and live in a community that maybe doesn’t even have a Wal-Mart? And yes, there are a lot of communities in Mississippi that don’t have a Wal-Mart yet!” Guice laments.

In rural or poor places like Mississippi the number of doctors per person is among the lowest in the country. Five years ago, the state Legislature established the Mississippi Rural Physician Scholarship Program to provide a full ride to medical students who agree to begin their practice in a rural area. There are two conditions: Students must originally come from a small Mississippi town far from health care, and they must agree to go back into practice in a rural area for four years after they graduate.

Guice is the recruiter for the program. She is fervent in her commitment to finding the perfect candidates.

“Basically I am looking for one of two personalities,” she explains. “Either the maverick who is going to go to med school and go back home and fix what is wrong with the health care system. Or the missionary. The student who says to me, ‘I thought about going to seminary but now I want to be a doctor,’ to which I say ‘Have I got a mission for you — it’s called Mississippi!’ ”

Guice believes students from small towns will put down roots and stay after their mandatory four years are up.

The success — or failure — of the program depends largely on her ability pick the right students.

Students like 26-year old John Russell McPherson, who’d already been admitted to med school when one day he got an email. “It said, ‘Do you want to work in a primary care setting?’ I said yes and kept scrolling. It said, ‘Do you want to work in rural Mississippi?’ Yes. ‘Do you want $30,000 a year?’ It had Janie’s email on it, so I signed up!”

McPherson is from the Delta town of Inverness — population 1,000 — and he outlines why he plans to return to the area he loves.

“Dirt roads. No traffic. Hunting. Outdoor stuff. That is what I am about and that is what I want to get back to,” McPherson says. “Work is going to be work and you are going to make a good living doing this, but it is really about being close to the family and hobbies that you enjoy.”

Drive an hour and a half from the medical school and you’ll find yourself in the Delta county of Humphreys. There are four doctors in Humphreys County for its 10,000 residents

Colorfully painted stone catfish statues line the streets of the town Belzoni, which is the Humphreys County seat and self-described “catfish capital of the world.”

In the Belzoni town square is a squat, white concrete building that houses the Gorton Rural Health Clinic. It happens to have a perfect example of what Guice wants to replicate: a father-son team of doctors Mack and Carlton Gorton.

The older doctor just turned 70 and has been running the clinic for 40 years. His roots go way back. His father had a drugstore in Belzoni, and when the town needed a doctor, Mack Gorton set up his practice. Eight years ago, Gorton’s son Carlton joined him. Carlton explains that he can’t imagine being anywhere else.

“It is a challenge to get people to come to the Delta to practice. So I think it is usually somebody who has to be here who has a love for people and love for what you are going to be treating here,” he says.

In rural areas of Mississippi, obesity and diabetes are the norm and life expectancy is far lower than the national average. At least one Delta county has no doctor at all.

Guice says the doctors who leave her program for these areas will help provide better treatment. They’ll also play another role: generating as much as $2 million a year in economic impact in a town.

The first of Guice’s rural scholars will be leaving residency to begin practice later this year, with more than 40 aspiring doctors currently in the pipeline.

Editor’s note: Another source of physicians for Mississippi is in the works. A new school of osteopathic medicine in the state expects to graduate its first Doctors of Osteopathy in 2015. The William Carey University College of Osteopathic Medicine was started in 2008 and received provisional accreditation in 2009.

This report is part of a partnership with NPR, Mississippi Public Broadcasting and Kaiser Health News.

PROF. PIERS J. HALE knew something was up when his students at the University of Oklahoma were clamoring this spring to get into his medical ethics class, which was formerly populated largely by social science majors. What led to the sudden burst of popularity, he discovered, were plans by the Association of American Medical Colleges to revise the medical school admissions test to incorporate a hefty dose of social science.

In addition to the hard-science and math questions that have for decades defined this rite of passage into the medical profession, nearly half of the new MCAT will focus on squishier topics in two new sections: one covering social and behavioral sciences and another on critical analysis and reading that will require students to analyze passages covering areas like ethics and cross-cultural studies.

“Enrollment doubled and I had to turn 20 away,” said Professor Hale, a professor of the history of modern science. “But what’s really exciting is not that taking this class will get these kids into medical school, but that it will help them become better physicians.”

The Medical College Admission Test is, of course, much more than a test. A good score is crucial for entry into a profession that is perennially oversubscribed. Last year, nearly 44,000 people applied for about 19,000 places at medical schools in the United States. So the overhaul of the test, which was announced last year and approved in February, could fundamentally change the kind of student who will succeed in that process. It alters the raw material that medical schools receive to mold into the nation’s future doctors.

Which is exactly what the A.A.M.C. has in mind. In surveys, “the public had great confidence in doctors’ knowledge but much less in their bedside manner,” said Darrell G. Kirch, president of the association, in announcing the change. “The goal is to improve the medical admissions process to find the people who you and I would want as our doctors. Being a good doctor isn’t just about understanding science, it’s about understanding people.”

The adoption of the new test, which will be first administered in 2015, is part of a decade-long effort by medical educators to restore a bit of good old-fashioned healing and bedside patient skills into a profession that has come to be dominated by technology and laboratory testing. More medical schools are requiring students to take classes on interviewing and communication techniques. To help create a more holistic admissions process, one that goes beyond scientific knowledge, admissions committees are presenting candidates with ethical dilemmas to see if their people skills match their A+ in organic chemistry.

The big question, of course, is how well a multiple-choice test can help screen for the ethereal mix of scientist and humanist and spiritualist that makes a good doctor. That is uncharted territory.

“Yes, we’ve fallen in love with technology, and patients are crying out, saying, ‘Sit down and listen to me,’ ” said Dr. Charles Hatem, a professor at Harvard Medical School and an expert in medical education. “So what the MCAT is doing has a laudable goal. But will recalibrating this instrument work? Do more courses in the humanities make you more humane? I think the best we can say is a qualified maybe.”

And then there are the more immediate concerns of pre-med students and their colleges, which are preparing for the seismic changes.

Where will students find time to take in the extra material? How to prepare pre-med students long primed to answer questions like “Where are the serotonin receptors 5-HT2A and 5-HT2B mostly likely to be located in hepatocytes” to tackle more ambiguous challenges, like: “Which of the following explanations describes why the Identity vs. Role Confusion stage likely affects views about voting and being a voter?”

The first class to experience the new test, which is traditionally taken junior year, will enter college this fall. Some current students could face it, too, as it has become increasingly popular to take a gap year or two before applying to medical school.

“I can definitely see students panicking about this,” said Dr. W. Alexander Escobar, director of the pre-medical mentoring office at Emory University, who is preparing new recommendations for coursework.

I should disclose that I have a history here: when I took the MCAT in the late 1970s, the test was all about basic science, which was not at all my interest; I had worked in labs and hated it. To make matters worse, the test was the day after my 21st birthday. That landmark celebration was lost to miserable cramming in physics formulas and biological pathways.

But I went to medical school in the 1980s — heady years for basic science, when new technologies like M.R.I.’s expanded diagnosis, fiber-optic instruments allowed for minimally invasive surgery and recombinant gene experiments paved the way for new tests and medicines that could cure hard-to-treat diseases. Medical schools saw their primary mission as churning out researchers, biomedical engineers and academics who could apply the latest research on gene splicing to the treatment of cancer.

“With the growth in scientific knowledge, we were focused on making sure doctors had a good foundation in hard science,” Dr. Kirch said. Indeed, from 1942 to 1976, the MCAT had included a broad-based knowledge section called “Understanding Modern Society.” Liberal arts questions were eliminated in 1977.

Over the next two decades, the pressure in medicine to maximize the technology and minimize the healing arts only increased, as efficiency-oriented health care systems gave doctors less time to talk to patients, and insurance reimbursements rewarded doctors with high-tech specialties like radiology or those who performed procedures.

“I’m not a Luddite,” Dr. Hatem said, noting that the tide appears to be turning. “I know the importance of technology and testing advances, but we’ve let this substitute for listening and examining.”

Some experts have long identified the MCAT as a stumbling block in the often-failed quest to produce more caring, attentive doctors. It is a test that selects more for calculation skills than empathy. “The definition of readiness for medical education clearly has an academic component that the MCAT has captured well,” Dr. William McGaghie, a professor at Northwestern University, wrote a decade ago in the Journal of the American Medical Association. “But it also has professional and personal components, as yet unmeasured or measured poorly.”

And so the Association of American Medical Colleges began three years ago to redesign the MCAT, surveying thousands of medical school faculty members and students to come up with a test tailored to the needs and desires of the 21st century. In addition to more emphasis on humanistic skills, the new test had to take into account important new values in medicine like diversity, with greater focus on health care for the underserved, Dr. McGaghie said.

As a result, there will be questions about gender and cultural influences on expression, poverty and social mobility, as well as how people process emotion and stress. Such subjects are “the building blocks medical students need in order to learn about the ways in which cognitive and perceptual processes influence their understanding of health and illness,” explains the preview guide to the new MCAT.

While the guide avers that such material is generally covered in introductory psychology and sociology classes, surveys by Kaplan Test Prep have found that fewer than half of pre-med students currently take these courses, said Amjed Saffarini, executive director of Kaplan’s pre-health programs. The company estimates that the changes, including more advanced science questions on genetics and biochemistry, could effectively double the coursework for med school admission.

Getting pre-med preparation right is a high-stakes game for colleges, which attract applicants because of their medical school admissions rates. Virtually all are now scrambling to figure out how to revise pre-med programs. Will all students on the pre-med track be required to take psychology and sociology, for example?

Many colleges and universities say they are not ready to discuss plans. Columbia University, said Katherine Cutler, its director of communications and special projects, “has been evaluating its curriculum and, based on this review, will make recommendations for ways to prepare Columbia’s students for the new content.”

At Emory, Dr. Escobar has asked social science departments to advise him on which of their courses cover the topics outlined in the new MCAT preview guide, so as to advise pre-med students about what to take. “We don’t want to design a course specifically for pre-meds,” he said. “We want them to take what’s already there.”

Many colleges already require pre-med students to take distribution requirements in the social sciences, said Joy Kiefer, an assistant dean at Washington University in St. Louis. “Physicians need a solid foundation in not just science but behavioral science to get good patient outcomes,” she added.

But for pre-meds, such courses have long taken a distant back seat to core science courses. While pre-med students can choose any major, only 5 percent come from the humanities and 12 percent from social sciences. More than half of all applicants majored in biological science.

The mere fact that psychology, sociology and critical thinking will be on the MCAT is likely to change priorities, prompting science majors to think harder about topics like the perception of pain, informed consent, community awareness and the ethics of the Tuskegee Syphilis Experiment. “We wanted to send a strong signal at the undergraduate level that these are important elements,” Dr. Kirch said.

For students already juggling heavy courseloads of organic chemistry, physics and laboratory research, that prospect is somewhat daunting. “From what I’ve understood, the test will be more difficult,” said Farrah Bui, 20, a sophomore pre-med student at Princeton who is considering taking time off before medical school and thus might have to take the new test. “It’s difficult enough with so many stresses already,” she said. “I’d say, it’s discouraging — another thing I have to do.”

Still, Ms. Bui is finding value in the medical anthropology course she is taking this semester, and believes such courses are useful for producing better doctors. “I used to think of medicine as very methodical: you get the symptoms, find the diagnoses and treat,” she said. “Now it has made me think beyond pathology and biochemistry to the person. It’s made me think, ‘How will I communicate with them?’ ”

Professor Hale at Oklahoma said that, with a far larger component of pre-meds in his class, he had fielded new types of questions. “When pre-meds approach an ethics class, at first it’s: just tell me what to do to be ethical,” he said. “They’ll come saying they’ve been put in the class by an adviser, but then discover it’s relevant.”

How admissions officers will use the new information remains to be seen. Though medical schools say they want a test that selects for more well-rounded students, their reputations derive far more from the number of Nobel Prize winners they spawn, not from producing good bedside doctors.

And, anyway, can a standardized test — even one six and a half hours long (current duration: four and a half hours) — really discern the students most capable of giving emotionally to their patients, or measure facility with profound concepts like discrimination and morality and the emotional underpinning of disease? After all, few ethics professors rely on multiple-choice tests. The writing section on the current MCAT is being dropped because admissions officers said it was unhelpful, and largely ignored it.

The 153-page MCAT preview guide lays out what students need to know in detailed outlines that read like formulas for a math test. To wit, a part of a section on emotion:

Three components of emotion (cognitive, physiological, behavioral).

Universal emotions (fear, anger, happiness, surprise, joy, disgust and sadness).

Adaptive role of emotion.

Theories of emotion (James-Lange theory, Cannon-Bard theory, Schachter-Singer theory).

The Association of American Medical Colleges will be field-testing new questions over the next two years by tacking an ungraded section onto the current MCAT. But Dr. Escobar of Emory said that sociology professors were concerned that some of the required topics in the outline seem dated. Liberal arts colleges do not want their intro to sociology class defined by what’s on the MCAT.

The A.A.M.C. says the goal of the new MCAT is not just to find out what students know, but also how they think and who they are. And that kind of test is harder to cram for. “We’re not in the business of changing personalities,” said Dr. Saffarini of Kaplan Test Prep. “But we can offer practice scenarios.”

Dr. Hatem had this to say: “I know what society needs and what patients want. They want a doctor who is technically competent but who also understands who they are. How to get there is more complicated.”

This April 13, 2012 article is by Elisabeth Rosenthal, a medical doctor and international environment correspondent for The New York Times.

Exploring the intersection of scientific ideas about race and gender with medical practice and experimentation, the annual Porter L. Fortune Jr. History Symposium convenes March 8-10 at the University of Mississippi.

The conference, titled “Science, Medicine and the Making of Race,” is sponsored by the UM Department of History. Londa Schiebinger, the John L. Hinds Professor of History of Science at Stanford University, is the keynote speaker for the three-day event. Her talk, set for 5 p.m. March 9 in the Yerby Center Auditorium, isfree and open to the public.The focus of this year’s symposium is on addressing medical research on nonwhite bodies between the 18th and 20th centuries.

“My colleague, Theresa Levitt, and I decided upon the theme for this year’s symposium because there is so much fine scholarship being produced on medicine and the making of race,” said Deirdre Cooper Owens, assistant professor of history and conference co-coordinator. “We especially thought this year’s Porter Fortune symposium would be especially salient for the University of Mississippi community as we have ended a discussion on Henrietta Lacks, race and scientific research.”

While the symposium is geared mainly toward specialists, anyone curious about broad themes such as race, gender and science is welcome.
“We hope that the keynote address will be widely attended with members of the general public,” said Levitt, associate professor of history. “The sessions will draw together historians of science, medicine and anyone interested in these issues. I hope that it will be useful to talk with someone working on similar topics, from a different perspective.”

Owens said her hope is that panel participants will see how the university, especially its history department, is producing exciting new scholarship on race, gender, science and the history of medicine.

“Professionally, I believe scholars will be able to assess new trends in the history-of-medicine field and investigate how institutions like slavery, colonial settlements and even politicized movements have helped to either develop or influence the way doctors and scientists research and write about race,” Cooper Owens said.

Schiebinger is the author of “Nature’s Body: Gender in the Making of Modern Science,” winner of the 1995 Ludwik Fleck Book Prize, and “Plants and Empire: Colonial Bioprospecting in the Atlantic World” (French Colonial Historical Society, 2005), winner of the 2005 AHA prize in Atlantic History and the Alf Andrew Heggoy Book Prize.

“The Porter Fortune Jr. History Symposium is the most important public lecture series sponsored by the Department of History each year,” said Joseph Ward, chair and associate professor of history. “We hope that members of the general public, as well as UM faculty, staff and students, will take the opportunity to attend sessions that interest them.”

The university and the history department have conducted the Porter Fortune Symposium on various topics every year since 1975. A number of thematic sessions are planned in addition to the keynote address. Typically, selections of the papers appear in an edited volume.

“For 37 years, the Porter L. Fortune Symposium has been an important event in the scholarship of Southern history and the College of Liberal Arts,” said Glenn Hopkins, dean of liberal arts.

For more information, including a conference schedule, visit https://www.olemiss.edu/depts/history/.