Elizabeth Gaufberg

Educational Outcomes of the Harvard Medical School-Cambridge Integrated Clerkship: A Way Forward for Medical Education

Purpose The authors report data from the Harvard Medical School–Cambridge Integrated Clerkship (CIC), a model of medical education in which students’ entire third year consists of a longitudinal, integrated curriculum. The authors compare the knowledge, skills, and attitudes of students completing the CIC with those of students completing traditional third-year clerkships. Method The authors compared 27 students completing the first three years of the CIC (2004–2007) with 45 students completing clerkships at other Harvard teaching hospitals during the same period. At baseline, no significant between-group differences existed (Medical College Admission Test and Step 1 scores, second-year objective structured clinical examination [OSCE] performance, attitudes toward patient-centered care, and plans for future practice) in any year. The authors compared students’ National Board of Medical Examiners Subject and Step 2 Clinical Knowledge scores, OSCE performance, perceptions of the learning environment, and attitudes toward patient-centeredness. Results CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness. Conclusions CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

Into the future: patient-centredness endures in longitudinal integrated clerkship graduates

This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time.

The role of the hidden curriculum in "on doctoring" courses.

In this paper, we briefly examine the role of the hidden curriculum (HC) in a particular type of medical education format: the “on doctoring” (OD) course. Background: The Structure and Function of “On Doctoring” Courses Although no description currently exists in the medical education literature on the emergence, content, and purposes of OD courses, this somewhat new addition to the formal compendium of undergraduate medical education does have a considerable Internet presence. Searches for “on doctoring” courses (along with associated terms such as “art of medicine,” “art of doctoring,” and “physicianship”) reveal that a number of medical schools have adopted such an educational vehicle. While the content and length of OD courses can vary by school, the following description from the Geisel (Dartmouth) Medical School is not atypical in form or content. On Doctoring is a two-year course that provides an understanding of the role of the physician in the clinical setting and in the community through longitudinal clinical and small group learning experiences in the first two years of medical school. During the first year, the course will focus on patient interviewing, physical diagnosis, physical exam, patient write-ups from student’s [sic] clinical encounters, clinical reasoning, and developing the doctor-patient relationship. The second year builds on these skills with additional course work and a higher level of learning [1].

Professional Boundaries: The Perspective of the Third Year Medical Student in Negotiating Three Boundary Challenges

Background: The negotiation and maintenance of professional boundaries is a central developmental challenge for medical students in clinical training. The purpose of this study is to assess problem solving strategies, decisions made, level of confidence, and language used by beginning third year medical students when faced with professional boundary challenges. Description: Forty-two students in the first quarter of their third year at Harvard Medical School viewed three brief audiovisual “trigger” tapes, each depicting a medical student faced with a boundary challenge (the offer of a gift, a personal question from a patient, an errand request by a supervisor). Evaluation: There was a high degree of agreement and confidence among students about how to negotiate a monetary gift (reject) and how to respond to a patients “too personal” question (not answer and/or redirect). However, the students were less confident and more divided on the issue of whether or not to run a personal errand for the team at the request of a superior. Conclusion: Our findings have implications for medical professionalism curricula, especially regarding the importance of mentorship and role modeling in medical education. Effective professional boundaries curricula allow the student to problem solve and practice communication skills in boundary challenging situations.

Psychiatry in the Harvard Medical School—Cambridge Integrated Clerkship: An Innovative, Year-Long Program

ObjectiveThe authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education.MethodA longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry “immersion” experiences, and a variety of clinical and didactic teaching sessions.ResultsThe longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average.ConclusionLongitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

The Harvard Medical School Cambridge Integrated Clerkship: challenges of longitudinal integrated training

R ecently, in the world of medical education, much attention has been given to longitudinal integrated models of clinical training. Such models are designed to remedy the discontinuity inherent in traditional specialty-specific, randomlysequenced block rotations. These new programs feature continuities of patient care, curriculum and supervision. Students learn the cross-disciplinary skills of doctoring by engaging in close, longitudinal relationships with patients and teachers.

Alarm and altruism: professional boundaries and the medical student

‘M y boundary alarm is constantly going off!’ exclaims a new medical student pondering her interactions with patients. Medical training thrusts students into situations which require transgression of traditional social norms: yesterday’s ‘civilians’ look with trepidation at people’s naked bodies, and insert fingers into their most intimate spaces. They ask intensely personal questions of people they hardly know; and they cut up the bodies of people they once cared for – cradling hearts and brains in their hands. ‘Steadying the self’ in the face of such taboo violations is a major developmental task of the clinical years in medical school, but it is impossible to function indefinitely in limbo like this. Students must reconstruct the social norms, known as ‘professional boundaries’, that will in the future govern their relationships with patients. Successful boundary development keeps students from becoming overwhelmed by intimacy and intensity, allows them to retain and channel empathy, and makes altruism the operational principle of the professional relationship. Boundaries keep the student together and the patient safe.

Humanism, compassion and the call to caring.

Health professions education is at an important juncture. A series of pivotal reports call for significant reform in the way students are prepared for practice in an increasingly complex health care environment. At the same time substantial work is emerging to illustrate that health professionals are struggling in record numbers with burnout, depression, suicide and challenges of identity formation, which may arise from exposure to disparities between formal curricular teachings and messages imparted through the ‘hidden curriculum’.

Do Medical Students’ Narrative Representations of “The Good Doctor” Change Over Time? Comparing Humanism Essays From a National Contest in 1999 and 2013

Purpose To explore medical students’ conceptions of “the good doctor” at two points in time separated by 14 years. Method The authors conducted qualitative analysis of narrative-based essays. Following a constant comparative method, an emergent relational coding scheme was developed which the authors used to characterize 110 essays submitted to the Arnold P. Gold Foundation Humanism in Medicine Essay Contest in 1999 (n = 50) and 2013 (n = 60) in response to the prompt, “Who is the good doctor?” Results The authors identified five relational themes as guiding the day-to-day work and lives of physicians: doctor–patient, doctor–self, doctor–learner, doctor–colleague, and doctor–system/society/profession. The authors noted a highly similar distribution of primary and secondary relational themes for essays from 1999 and 2013. The majority of the essays emphasized the centrality of the doctor–patient relationship. Student essays focused little on teamwork, systems innovation, or technology use—all important developments in contemporary medicine. Conclusions Medical students’ narrative reflections are increasingly used as rich sources of information about the lived experience of medical education. The findings reported here suggest that medical students understand the “good doctor” as a relational being, with an enduring emphasis on the doctor–patient relationship. Medical education would benefit from including an emphasis on the relational aspects of medicine. Future research should focus on relational learning as a pedagogical approach that may support the formation of caring, effective physicians embedded in a complex array of relationships within clinical, community, and larger societal contexts.

The professional oath: pledge of allegiance or reflective practice?

them would constitute unethical undertreatment. In sophisticated settings, there are investigations that can rapidly exclude many of these diagnoses, but in poorer contexts one has to rely mostly upon clinical skills alone. For clinicians with poor knowledge, polypharmacy is arguably the safest policy. Thus, a more knowledgeable clinician might feel confident in making a diagnosis of viral encephalitis, and not administer these other treatments, risking an erroneous diagnosis. Is this therapeutic nihilism? Obviously, there are details that might assist in making better clinical judgements, but I hope this case illustrates the complexity of defining underand overtreatment in resource-poor settings.