The University of Colorado’s School of Medicine is the first in the country to shift entirely to a new way of training doctors, with the hope of producing graduates who more naturally see patients as the center of the health care system.
In the typical medical school model, students spend one to two months learning the basics of a specialty, such as psychiatry or pediatrics, before rotating to the next one. In CU’s “longitudinal integrated clerkship” model, students work under experienced doctors in multiple specialties at the same time, said Dr. Jennifer Adams, assistant dean of medical education overseeing clinical clerkships.
For example, someone might be in the family medicine clinic every Monday morning, with their other rotations spaced out throughout the week, she said.
The students at CU’s Anschutz Medical Campus in Aurora also follow a group of patients over the course of the year. Their patient panels need to include certain types of patients, including a person with a mental health condition, someone seeking obstetric care and a patient nearing the end of life, said Dr. Emily Gottenborg, a hospitalist who oversees the students at UCHealth’s A.F. Williams Family Medicine Clinic in Denver’s Central Park neighborhood.
But they also have some freedom to invite patients to join their panel based on their interests, she said.
If patients give permission, their electronic medical records send notifications to the students if they visit an emergency room or are hospitalized, Gottenborg said. The students only have 15 patients in their panel — compared to hundreds or thousands for full-fledged doctors — so they won’t drown in notifications, she said.
Haider Sarwar, a medical student from Chicago, said he wasn’t sure what a longitudinal clerkship would mean when he chose CU, but he enjoyed the experience. He plans to specialize in ophthalmology and has an interest in eye surgeries, so he chose panel patients who had procedures coming up.
Following the patients brought some surprises, Sarwar said. He hadn’t expected that one of his obstetric patients, who was visiting for a first-trimester appointment in July, would be someone he’d seen before when she needed a minor surgery. In another case, he came across a patient who needed a follow-up procedure to fix a broken arm again while working in the psychiatric clinic, and learned the patient’s calm reaction to needing another surgery came after anger-management treatment.
“Being able to have that perspective helps you to make decisions,” he said.
It also makes students feel more like advocates for their patients, and helps build their confidence as doctors, Sarwar said.
The students in the longitudinal model seem to have an easier time making connections between specialties than those educated in the traditional model, Adams said. They also scored higher on patient-centeredness and empathy, while not doing any worse on academic measures, she said.
“Six or seven years after (longitudinal integrated clerkships), students are still more empathetic,” she said.
Pilot program launched 10 years ago
The CU School of Medicine started with a pilot longitudinal program at Denver Health in 2014, then slowly expanded it over the past decade, Adams said. For the last two years, all students have learned in the longitudinal model in their second year of medical school.
The longitudinal model is more complicated than the traditional block model, with one coordinator for every 12 students, Gottenborg said. Schedules have to offer some flexibility, so students can follow their patients, but they also need to get their hours in each specialty, she said.
Dr. Emily Lines, an assistant professor of family medicine and medical director of the Williams clinic, said she worked as a preceptor, or on-the-job teacher and mentor, for students before and after the change to a longitudinal model. The model fits family medicine particularly well, because students are unlikely to see effects within a month or two if they counsel patients on lifestyle changes, she said.
“One of the things to learn in primary care is that changes in health don’t happen overnight,” she said.
Learning from multiple types of physicians at the same time also gives students the ability to make connections they, or even their preceptors, might have missed otherwise, Lines said. For example, students have talked about seeing surgeons decline to move forward with patients referred to them from primary care, suggesting that different doctors’ ideas about when the time has come for a more aggressive approach don’t always line up, she said.
“You get to see the other side of the coin,” she said.
As of 2016, 142 medical schools offered a longitudinal option, according to the Association of American Medical Colleges. The group didn’t have more recent data availableon the total number of schools with a longitudinal option, but said CU is the first to send all students through that model for their clinical year.
“They get to see people get well”
Having students follow patients instead of physicians gives them a fundamentally different view of the system, said Dr. Abraham Nussbaum, a psychiatrist, assistant dean of the CU School of Medicine and chief education officer at Denver Health. Nussbaum oversaw the pilot program and has since written a book about the model shift, called “Progress Notes: One Year in the Future of Medicine.”
A longitudinal model also expands their education beyond the body and what can go wrong with it physically, to put more emphasis on patients’ emotional and material needs, he said.
“The illnesses today also are illnesses of our communal and social life,” he said.
Changing the model has been a challenge, because doctors overseeing students’ training almost all learned in traditional blocks, Nussbaum said. But the longitudinal setup does seem to increase students’ interest in less-popular specialties like psychiatry, he said.
“In the old model, they saw people at their sickest” when they were in hospitals, he said. “In the new model, they get to see people get well.”
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