Medical education is, necessarily, a process of learning incrementally the many subjects that a practicing physician needs to know. Medical schools worldwide have developed a variety of approaches aimed at providing students with both the necessary knowledge base and the skills to apply their knowledge in clinical situations. In most schools, students take a series of basic science courses followed by organ-based pathophysiologic courses, which are often associated with hospital- or outpatient clinic-based teaching in which students learn how to interview patients and apply what they learned in earlier courses. Medical educators assume that, over the course of the four years of medical school, students will be exposed to enough basic and clinical knowledge that, by graduation, they will have begun to organize all of the acquired information, eventually evolving into well-rounded physicians during their postgraduate training.
However, given the vast range of information and approaches to clinical care that students encounter during their training, many medical educators share a major concern: how can we be sure that a student has successfully integrated all that should be known about a patient? And how do we know that the student has developed the higher-level thinking skills that allow him or her to integrate all of the pertinent information and apply it to clinically important decision making? It is from this central concern over the integration of knowledge and application of complex thinking skills that we conceived the Mentored Clinical Casebook Project (MCCP). The broad learning objective of the MCCP is that students begin to understand that every patient they will encounter throughout their careers brings to the clinical intervention an entire life, multiple aspects of which will affect the patient’s reaction to illness and treatment. The MCCP is centered around the idea that it is more important for students to develop a coherent model of learning for a lifetime than it is for them to attempt to learn every detail in a textbook.
Providing a Framework for Information Integration
The MCCP was implemented at Harvard Medical School (HMS) in 2003. It is a yearlong project in which each participating medical student works with one clinician and one patient. The student spends as much time as possible with the patient in office and hospital appointments and also visits the patient’s home. The student, in consultation with his or her mentor, defines all the components of the patient’s health situation (including the patient’s story, the pathophysiology of the health problem, socioeconomic issues, cultural issues, etc.). In other words, the student must identify and investigate all the factors that comprise the patient’s health care life. Then, the student writes this patient case in a book format divided into chapters, using references from the primary literature. The writing of the casebook is an essential part of the project, because it is the mechanism by which the student organizes his or her thoughts and expresses—as well as sees—what he or she has learned.
We have structured and run this program with first-year HMS students during the past three years, and we have received overwhelmingly enthusiastic reviews from student and faculty participants. What has become clear is the successful accomplishment of a number of goals that many medical educators strive to achieve. First, each participant is able to develop a close mentor–student relationship, designed around a project of mutual interest. Second, students develop lifelong learning skills, as each student learns how to obtain and manage a number of diverse pieces of information about one patient’s health issues, organize this information into a logical and clinically useful form, and present a coherent book about the patient and his or her health care life. Third, students hone techniques of finding, choosing, interpreting, and applying primary literature to a particular patient’s health care issues. Finally, students are able to develop a style of clinical care that takes advantage of each student’s unique intellectual strengths, such that the student develops a learning style and clinical approach that will optimize future patient care.
The MCCP’s Design and Implementation
The MCCP was started with first-year students, although we believe the students could do one casebook per year for all four years of medical school, depending on a particular school’s curriculum. There are two aspects of the first-year experience, however, that are worth noting. In the first year, students observe the health care system (probably for the last time) more like a patient than a medical professional. The casebooks chronicle, in part, the students’ health care world view, giving future physicians a look at the inception of their professional transformation. Second, by virtue of the working relationships established between students and their faculty mentors and project advisors (PAs), students are able to consult more closely with senior faculty than might normally be likely during the first year of medical school.
The student–mentor relationship
In the initial year of the MCCP, we asked for student volunteers from the incoming class (in its first year, 2003–2004, the course was a noncredit course, but it has been for credit ever since), and over 100 of the 164 students expressed a strong desire to participate. We randomly selected 20 students. (In the second year, we had a similar student response, and we selected 50.) That first year, we sent an all-faculty e-mail seeking mentors, and over 350 faculty eagerly responded. From these, we chose 20 physicians who reflected diversity both in geographic location and in specialty. (In the second year, we did not solicit faculty by e-mail, because almost all the original mentors wanted to participate again, and it was quite easy to find others from the original list of interested faculty).
When selecting faculty mentors, we specified two main criteria for clinical specialty: (1) the mentor had to select a patient of his or her own to follow, and thus all mentors had to be active clinicians, and (2) the patient had to have a chronic clinical issue (not necessarily a serious issue, but one that needed routine follow-up). The mentors have come from a wide range of specialties, including general internal medicine and internal medicine subspecialties, pediatrics and pediatric subspecialties, psychiatry, ophthalmology, endocrinology, neurology, hematology, general surgery, transplant surgery, pulmonary medicine, and obstetrics–gynecology. The mentors ranged in job title from department chairs and division chiefs to senior fellows.
Each student was assigned one patient. Focusing on only one patient is very important to the success of the MCCP, because the goal of the project is to learn deeply all there is know about patient care, using one patient as the model. We have found that by using the single-patient approach, by the time the students write their casebooks, they have come to understand not only their individual patients in detail, but that the pieces of their patients’ health care lives (e.g., issues involving basic science, pathophysiology, psychology, socioeconomics, cultural differences, economic concerns, etc.) are part of every patient’s situation.
During these first three years of the MCCP, each student and mentor pair has communicated in person, by phone, or by e-mail on a weekly to biweekly basis over the course of their year of involvement. Any time spent on the MCCP has been completely outside the student’s regular course work. Because of this, the students’ involvement in the course has been somewhat discontinuous. Some weeks, students have been able to devote ample time to the project, but a heavy load of classroom work may have interrupted their involvement during other weeks. Each student has done at least one home visit but has also met with his or her patient on multiple occasions in whatever setting was appropriate. Many students have even attended family get-togethers or other personal occasions, depending on the relationship they have developed with their patients.
The role of the PA
During the conception of this project, we were concerned that it could be too solitary an experience for the student. We believed that students would benefit from sharing their thoughts, experiences, and issues with other student participants. To achieve this exchange, we asked a group of professors to act as PAs. The role of the PA is to provide outside perspective and guidance, to serve as a resource in connecting students with other experts in fields related to their projects, and to facilitate student discussion. The students were assigned to meet, in groups of three, with an assigned PA every four to six weeks to discuss their patients’ stories, basic and clinical issues, and the writing of their casebooks. The PAs thus far include medical school deans, hospital presidents, basic scientists, senior faculty, and full-time clinicians. As with the student–mentor relationship, we have found that the student–PA relationship has been greatly valued by both the PAs and the students, thus adding an extraordinary richness to the MCCP experience.
Expectations for the student
Since the program’s inception, we have upheld several expectations for students who participate in the MCCP. During the year, the student is expected to obtain the patient’s story, determine the components of the patient’s health care life (these eventually become the casebook chapters), and write a coherent, organized, in-depth casebook, illustrating a mastery of this patient’s health struggles and a deep understanding of all of the issues involved in the case. In accomplishing these goals, students must meet two other expectations. First, they are required to use the primary literature as a source of knowledge. We discourage the use of textbooks, other than as a starting point. Rather, students need to find, interpret, and appropriately reference supportive literature. Students learn how to best select, evaluate, and apply specific literature, both individually and in discussions with their mentor and PA. Second, we expect the students to discuss specific issues with experts (other than their mentors and PAs) in relevant fields. This enables the student to clarify confusing questions and to understand the issues in a more sophisticated manner. A student’s mentor, PA, or one of the five of us (authors) who comprise the MCCP steering committee can identify an expert in a specific area. This aspect of the project has been especially rewarding for the students because they have had the opportunity to interact with authorities in basic science, clinical trials, health care finance issues, legal questions, and other areas. It has been striking that these individuals have been delighted to spend time speaking with the students about a particular patient-oriented question. The expert can also direct the student to appropriate literature that will help in understanding the issues germane to their patient. These experts have played an essential role in the MCCP, because mentors are not expected to know everything the student needs to learn, and, further, the student needs to become comfortable with the process of seeking outside advice and with professional collaboration.
The role of the steering committee
The entire project is overseen by a steering committee that currently consists of the five authors. The roles of the steering committee are as follows:
1. Recruitment of faculty mentors and assignment of students to mentors.
2. Education of faculty about the expectations and roles for the mentors and PAs.
3. Oversight of the performance of students, mentors, and PAs involved in the project. We achieve this by contacting students and faculty throughout the year to determine whether there are any problems, concerns, or observations of the participants.
4. Implementation of solutions to various problems. These problems have included the selection of inappropriate patients for this project, poor interactions between mentors and students, and the unexpected deaths of patients.
5. Assessment of how well the overall educational goals are being met and identification of any changes or improvements required in the project. We are using various assessment tools, such as questionnaires and personal interviews, to create project assessments.
The students’ end-of-the-year projects
At the end of the academic year, the students have two final projects. First, they must make a presentation in front of peers, mentors, and PAs in which they discuss a specific aspect of their patient’s health care life. These presentations are typically 10 minutes in length and are followed by a few minutes of questions from the audience. Whereas the entire group of participants attended one presentation session at the end of the project’s first year, as the enrollment numbers have grown, we have had to divide participants into smaller groups so that one session does not last more than three hours. We hold these presentation sessions as part of a dinner gathering. The oral presentations have given the students the valuable opportunity to prepare and present a formal talk in front of a sophisticated audience. They provide an impetus for the students to finish their casebooks. In addition, they give the students the challenge of organizing their patients’ information in a slightly different way than they do in their final casebooks. Students have been quite creative with these talks, using slides, charts, and graphic representations to illustrate their points.
For 2005–2006, casebooks ranged from 30 to 90 pages and contained between 20 and 145 references. Although we instruct students that each casebook should contain a chapter on the patient’s story, one on basic science/pathophysiology, and chapters on any other pertinent issues, we purposely do not tell students how to construct their casebooks or what style or format to use. We believe that because this project is intended to help the students become aware of their own, unique styles in the context of practicing medicine, too much specified structure would inhibit that process. The result has been a wide variety of excellently written casebooks that effectively relay the patients’ stories and information but that are individual to each student. The only other specific section we asked students to write was a chapter of their personal reflections. With this particular segment, we stressed that students should consider their own reactions and become observers of the world around them. In the reflection sections, the students have produced insights into such issues as their personal growth as physicians, the doctor–patient relationship, the mentor–student relationship, the doctor–society relationship, and the current health care system.
Assessment of the casebook
Finally, after the casebooks have been written and presented, two readers read and assess each one, giving written feedback to the students. Much to our delight, we have not had a problem finding willing readers. For at least one reader of each casebook, we seek out individuals who work in the same area as the patient’s principal issue. We have developed an assessment tool for the readers (Appendix 1) that asks them to evaluate the breadth of the casebook, the depth of the student’s understanding, the clarity of the writing, and the use of the literature. In general, the students have produced excellent casebooks. As with any project, there has been a range of quality, but the vast majority of the casebooks have been rated from very good to superb.
Over the years, a number of efforts have been aimed at teaching students the full scope of medicine while integrating multiple areas of medicine. These educational approaches, however, have been directed toward placing a specific area (e.g., musculoskeletal disease) into a larger context, or integrating basic science into a clinical curriculum.1–5 We believe that our approach is singular in its effort to teach students what comprises the entirety of a patient’s health care experience.
There have also been many approaches to writing in medical education, including journaling and applying writing in a sophisticated way to express complex feelings and ideas.6–12 These approaches have been very successful, but they work towards different goals than those of the MCCP. Our goal is to use writing to help students crystallize their experiences with the individual patients.
Another initial concern to us was recruitment of faculty. We have been pleased to find no resistance in this regard. In fact, we have had many more faculty volunteers than students. So far, we have limited the project to 50 students per year, but there are discussions to enroll the entire class in the project. Over the first three years of the MCCP, most of the mentors and PAs who have participated once have returned to participate again. The mentors and PAs include deans, department chiefs, division chiefs, staff physicians, and researchers throughout the Harvard medical community.
Clearly, it is important to determine whether the MCCP has been effective in achieving our proposed goals. To that end, we continue to work on devising assessment tools aimed at quantifying how successful the project has been. These assessment tools are being developed in collaboration with educators at HMS. In the future, we will report on our findings. We believe that we need to assess students who participated in the MCCP during their first year when they are in their third and fourth years. This way, we can better determine the effects of the projects on students’ integrative skills and on other decisions, such as residency choice. We will also ascertain how the students view the mentored casebook compared with other medical school experiences.
The MCCP offers an educational approach that achieves the following goals:
1. effective mentoring, because the students and mentors are united over projects of mutual interest;
2. effective integration, because the students learn all that comprises a patient’s health care life, so that they can incorporate these pieces into a coherent, organized whole;
3. effective use of primary literature, because its application to a pertinent and meaningful clinical situation enhances learning;
4. reengagement of a wide variety of medical faculty throughout the community, as indicated by the extensive faculty interest; and
5. development of a lifelong learning style and skills that serve as the basic structure on which students can place all that they will need to know and apply while delivering patient care in their future clinical careers.
In conclusion, the MCCP is not simply another medical school course but, rather, a novel way to accomplish a number of medical educational objectives. It is a student-driven, patient-centered project; hence, the responsibility for learning comes from the student and is primarily centered on a single patient. The student has the luxury of investigating one patient thoroughly. With this focused perspective, the student becomes uniquely motivated to find the answers to issues through discussions with his or her mentor and PA, through interactions with experts, and through the use of primary literature. The work that students do for their mentored casebooks not only enhances their medical school experience; it provides them with valuable tools they will be able to use throughout their careers.