by Susan Davis
Source: UCSF Medical Alumni Magazine
Medical student Rebecca Falik (right with preceptor Kim O'Hair, NP and patient) is taking an innovative approach to her third-year clerkships. Instead of registering for the traditional six clinical blocks (family medicine, medicine, obstetrics and gynecology, pediatrics, psychiatry, neurology and surgery), Falik signed up for UCSF School of Medicine's "Parnassus Integrated Student Clinical Experiences" (PISCES) program.
In PISCES, students like Falik, 28, spend an entire year at UCSF Medical Center and work one-on-one with faculty from 12 core medical and surgical specialties simultaneously, rather than going through their rotations one after another. This approach allows them to develop a more multidisciplinary understanding of the specialties, the patient experience and how UCSF Medical Center works.
"I like being at one place," says Falik, "because I start to recognize the names of the clinics and the doctors that all my patients see, and I am comfortable with the mechanics of the computer system, the paperwork, etcetera."
Each student also follows a cohort of patients (usually between 50 and 80), whom s/he tracks through their care and across various specialties and clinics, a feature designed to develop doctors with a deeper understanding of the patient experience. A pager system notifies students when their patients come to the emergency room, labor and delivery, hospital admissions, and operating room and clinics, so that the students can meet up with them at the hospital.
That was Falik's experience with patient Helan Lee, 38. She accompanied Lee to her prenatal appointments for several months, went with her when her baby was delivered, and came to well-baby visits. "She was a great advocate," Lee says. "She was very sweet and able to ask very detailed questions for me. She was a big help."
"This program gives students a real role in taking care of patients," says Ann Poncelet, MD (left), a professor of neurology at UCSF and co-director of the PISCES program.
The PISCES idea emerged from a series of curriculum working groups and retreats in 2004-2005, and from research into models at several other schools and campuses that have implemented similar "longitudinal clerkships" (e.g., Harvard, South Dakota and UCSF Fresno). In 2007, a pilot program was launched at UCSF with eight students.
The hope was that a new kind of program could address some of the long-standing issues in traditional medical education. These include a shrinking role in patient care, fewer opportunities to assess undiagnosed patients, increased fragmentation of medical care among many different settings, and a lack of continuity between rotations.
"We're at the front edge of a growing wave in medical school curriculum," says Helen Loeser, MD (right) , associate dean of curriculum for the school. "There are only a handful of other schools doing this nationally. We are finding it to be a very rich and effective model for learning."
Sixteen third-year students are enrolled in the PISCES program in its fourth year, and the benefits are becoming clear. Take, for instance, the notion of staying in one medical center, rather than rotating through several. "By spending a chunk of time in one setting, the students really get to know the institution," Loeser says. "That means they can navigate the system better, which in turn allows them to better help their patients access care, whether it's social services, community resources, specialist referrals or diagnostics."
The year-long work in all 12 specialties helps students learn to assess patients even when the preceptor isn't there, Falik says. "It's what I call the spiraling concept of education," she notes, "wherein we touch upon one subject and then revisit it in a deeper way as time passes, and then the spiral continues. This can help the skills I'm learning really stick."
"For example, I might watch my preceptor perform a neurological physical exam. But then I get to do the exam the next time, with her watching. And when I find myself taking care of a patient outside of the neurology setting, I feel confident doing the neuro exam without my preceptor watching."
The exact nature of the student-patient relationship varies. While Falik accompanied Lee in welcoming her newborn, third-year medical student Aubrey Gilbert, 31, was most helpful to patient Tracie Brodhun, 48, by answering questions via email and phone.
Brodhun recalls that she had just finished her consultation with her surgeon at UCSF, when he suggested that she might want to team up with Gilbert. "He told me she could answer my questions," says Brodhun, whose thyroid cancer had returned after 20 years. "And I thought, 'Oh, that's nice. But I really don't think I'll have any questions.'" Of course, she did end up having questions. And Gilbert was the perfect respondent. "Aubrey was just so accessible and approachable," Brodhun says. "She's an incredibly kind, warm person."
Reflecting on the experience, Gilbert says, "I was able to experience health care much more from a patient perspective. I was also able to see what work is like from an attending point of view."
PISCES students have preceptors in each specialty. These one-on-one relationships help the students receive a more personalized education. "You get to maintain relationships with giving and wise doctors," Falik says.
But it's an equally good opportunity for the faculty members. "Working with a student over one year can be far more rewarding than working with random students in a rotation," Loeser says. "But it does take time and attention. These teachers have to be able to look at a student in a longitudinal way – 'here's where she is now, here's where she's headed, here's what she needs to learn.' It's much more intensive, in terms of faculty development."
For patients, of course, having a medical professional who cares about them available pretty much night and day is invaluable. "Students often speak more in lay terms," Poncelet says. "And they can help patients with transitions in care, including going from ER to specialists, or going home after a stay in the hospital. The students get to know the patients as people, not just patients. It can be very reassuring to have that kind of emotional support."
Gilbert learned that first-hand while working with one internal medicine patient last fall. "He had a very difficult and abrasive personality and behavior," she says. "He was actually barred from certain clinics based on his abusive treatment of staff." But when she accompanied him to his first dialysis session, she discovered he was frightened. "He opened up to me and shared his feelings, and we had a long conversation over his three-hour dialysis session. By the end I understood a lot more about his history and some of the factors that were contributing to his outlook and approach to health care."
"That has provided me pause whenever I have interacted with difficult patients since," she continues. "I try to remember that everyone has traveled their own path to arrive where they are, and everyone has had different experiences contributing to their perspective and how they interact with the world."
One of Falik's most noteworthy patients was a young woman who had just been diagnosed with multiple sclerosis – and who was pregnant and had a heart condition. "Dr. Ellen Mowry thought this would be a great learning experience for me to follow the patient through all of these different clinics and trials in her life," Falik says. "I met with the patient a couple of times, performing the neurological exam on her once, watching her get a thorough heart exam another time, and then I got to help deliver her baby, and help suture up her belly after her C-section."
"Now I see her back in neuro for her MS check-ups, and she brings along her infant. I get to see him grow, and that is so wonderful and makes me feel like life is really a miracle, even in the midst of the hospital setting where there is so much illness and tragedy. In PISCES I can really follow the cycle of life, if I so choose."
Without question, PISCES is not for every student. "It tends to attract students who are self motivated, self-starters and very organized," Loeser says, "students who really like engaging with responsibility and might not need as much structure as others." Adds Gilbert, "They also really have to be very outgoing and good at communicating."
So far, "students in PISCES do just as well as students in the more traditional rotations with every single marker that we measure," Loeser says. "But they actually score higher in terms of their sense of well-being and professional development in their third year. They know why they're in medical school. In the more traditional third-year path, students suffer from constantly being at the bottom of the heap, of not knowing what to do, each time they start a new rotation."
PISCES students are also getting more opportunities to see new patients in acute care and ER settings, where, Loeser notes, "they're not already packaged up and ready for care. They are undifferentiated, which gives our students tremendous opportunities for learning to assess patients."
Poncelet says she's looking forward to the time when she hears patients walking into a clinic and saying "I want a student. The care is better when we have students." At that point, she notes, "we would know that medical education and medical care are truly aligned."
Photo of Ms. Falik and patient by Brian Auerbach.