Systemic lupus erythematosus (SLE) represents a chronic autoimmune mediated disease with a spectrum of manifestations involving the cutaneous, rheumatologic, neurologic, renal, hematologic, cardiovascular, and pulmonary systems. The presence of any 4 of the 11 criteria outlined by the American College of Rheumatology is often used to make a clinical diagnosis of SLE.1 Multiple clinicians are frequently required to coordinate the care of individuals with lupus, given the potential extent of organ involvement.
SLE: Clinical Background
Although the range of clinical manifestations of SLE is wide, cutaneous findings are often noted. Retrospective analyses of patients diagnosed with SLE have estimated that 72% to 85% of SLE patients have some form of skin involvement, and up to 25% may have a cutaneous manifestation as their first presenting sign of disease.2 Lupus may also manifest as a purely cutaneous condition without systemic involvement, whereas the cutaneous manifestations in some cases foreshadow the development of future systemic symptoms.3 Patients with skin involvement often require systemic treatments to achieve disease control in addition to topical anti-inflammatory agents.4 The impact of cutaneous manifestations of lupus on a patient’s quality of life is noteworthy. Patients report a significant emotional impact of their disease, particularly with symptoms of photosensitivity, rash, and hair loss.5
Systemic lupus patients also report a significantly decreased health-related quality of life comparable to that of patients with other medical conditions affecting multiple organ systems, such as those with human immunodeficiency virus (HIV) infection.6 The breadth of clinical manifestations and underlying complex molecular pathophysiology in lupus provide a novel mechanism for integrating several fundamental concepts in medical education.
Clinical Electives in U.S. Medical Education
The conventional paradigm in U.S. medical education initiated near the turn of the last century has divided the four-year course of undergraduate medical education into two basic science or “preclinical” years, followed by two years of clinical clerkships during which students rotate through different clinical fields (e.g., internal medicine, pediatrics, surgery, obstetrics–gynecology, neurology, and psychiatry) and gain exposure to the practice of each specialty.7 The fourth and final year of undergraduate medical education often includes opportunities for students to participate in elective rotations that may complement their chosen field of graduate medical education.
Undergraduate curriculum reform efforts over the last decade have explored innovations to integrate basic sciences into the clinical years to reinforce the links between pathophysiology and patient care.8 Common methods for integration include lectures, seminars, and laboratory experiences provided in conjunction with clinical rotations for fourth-year medical students. An additional concept gaining interest in curricular reform is the increasingly interdisciplinary nature of modern medical practice. As patients often rely on multiple physicians and associated practitioners across a variety of specialties for the integrated management of complex illnesses such as breast cancer or chronic conditions such as renal disease,9–12 educating medical students in this collaborative environment becomes increasingly important. At present, few medical student elective rotations include longitudinal patient care across multiple clinical specialties and environments. As noted above, lupus represents a disease process with complex pathophysiology for students to learn from providers across several fields, including dermatology, rheumatology, nephrology, and cardiology, in both pediatric and adult patient populations. Moreover, as the diagnosis and management of lupus rely heavily on basic science and clinical immunology, a strong connection to the basic science curriculum can be easily established. We report here on the development, implementation, and results of a novel interdisciplinary, multisite clerkship centered on patients with a single disease: lupus.
Development of the “Understanding Lupus” Clerkship
Two of the authors (R.A.V., P.S.) con ceived the idea for the course. During the 2008–2009 academic year, we held focus groups with medical students at Harvard Medical School (HMS) to solicit feedback regarding curricular options for fourth-year elective rotations. Table 1 presents selected feedback from the focus groups. A total of 16 students participated in the focus groups. We used these student viewpoints to design a one-month course elective entitled “Understanding Lupus: A Multidisciplinary Approach to Systemic Disease.”
On the basis of our learners’ needs and taking into account the diagnostic and therapeutic challenges of caring for patients with lupus such as the ever-changing spectrum of complex medication management, we designed a monthlong course with several key goals and objectives. List 1 outlines the primary course learning goals and objectives.
One author (L.N.), an HMS educator whose expertise is in undergraduate and graduate medical education, reviewed the course structure, curricular requirements, and assessment methodologies. The concept and design of the elective were built using constructivist and social context learning theories as well as a spiral curriculum framework. Incorporating direct clinical care experiences into the elective was based on Dewey’s constructivist writings that stress the importance of students’ active involvement in the learning process and argue that educators must provide experiences that are immediately valuable and may be carried forward and influence future learning.13 By applying Bandura’s14 social context learning theory, we understood that the elective needed to provide exposure to the diverse clinical environments of rheumatology, dermatology, and immunology to allow students to observe and learn from varied clinical role models in order to develop an integrated understanding and approach to the management of systemic lupus. Inclusion of didactic seminars emphasizing basic science as well as integration of basic science principles in the elective’s clinical experiences represent application of Bruner’s15 spiral curriculum model. Applying the spiral curriculum model to the elective allowed for continuity and vertical integration between the preclinical and fourth-year medical school curricula.16
We submitted the course to the HMS Curriculum Committee for approval, and following enthusiastic endorsement, we offered the course to students for the first time in 2009. The HMS institutional review board granted a waiver of IRB exemption for the use of deidentified student comments obtained from student feedback for publication in the medical education literature.
Chart 1 presents a sample student rotation schedule for “Understanding Lupus.” Over the course of four weeks, each student is able to participate in several required core components of the rotation. In addition, they are able to supplement their time with individualized exposures tailored to their laboratory and clinical interests, allowing them to maximize their personal educational value from the rotation.
The standard core experiences in the rotation include several weekly clinics in both rheumatology and dermatology. Students see patients with lupus independently and present their assessments to faculty and fellows in both adult and pediatric specialty clinics. During patient encounters, students and faculty highlight review of clinical histories, laboratory values, medication management, and physical exam findings.
Students also participate in outpatient, interdisciplinary connective-tissue disorder clinics staffed jointly by specialists from both dermatology and rheumatology. Time spent in this particular clinic exposes students to the management of patients with challenging systemic conditions such as psoriasis with psoriatic arthritis, systemic sclerosis, and dermatomyositis, in addition to patients with both cutaneous lupus and SLE. Supplementing these experiences, students spend time in nephrology and neurology specialty clinics focusing on the management of patients with systemic involvement of lupus.
Students gain additional clinical exposure through participation on the inpatient consult services for both rheumatology and dermatology. They spend selected half-days seeing inpatients whose primary teams request urgent dermatologic or rheumatologic intervention, and they are able to track their patients’ progress through regular daily follow-up rounds with the fellows and faculty.
A novel educational experience incorporated into the four-week block is the opportunity for students to witness multidisciplinary, longitudinal care of an individual patient. During the first week of the monthlong rotation, students identify a patient whom they would like to follow during their subsequent time on the rotation. Once a suitable patient is identified, and patient permission granted, the student arranges to accompany the patient to other clinical encounters, such as infusion appointments for immunosuppressive therapy, blood work encounters, outpatient testing (such as radiologic, ophthalmologic, or neurologic testing), and other clinical visits related to the management of lupus or other comorbid conditions. Given the chronic and incurable nature of SLE, this course component was designed to specifically raise students’ awareness of the known significant impact of SLE on health-related quality of life.
Both the diagnosis and management of lupus involve the understanding and interpretation of clinical laboratory data, particularly related to autoantibody testing and complement levels. To enhance student familiarity and comfort with these measures, students spend a day in the Brigham and Women’s Hospital Clinical Immunology Laboratory working with the physicians and technicians to understand the requisite steps in processing samples for autoantibody interpretation and the visualization of immunofluorescence patterns. Supplemental required reading on the evolution of these techniques is also supplied and formally discussed with the course directors to further student understanding of the historical perspective on autoantibody testing as well as newer developments in the field. Clinical encounters routinely stress practical implementation of such tests, and students are asked to follow-up on laboratory tests ordered for patients seen to reinforce the clinical correlation of such testing.
Students are exposed to current advances in the medical field through weekly seminars incorporated into the “Understanding Lupus” rotation. Students attend a weekly rheumatology journal club and a weekly Harvard University immunology seminar. The journal club focuses on review of current, evidence-based literature presenting advancements in clinical care, whereas the seminar emphasizes translational basic science research in the field of immunology and its impact on approaches to patient care for individuals with lupus or other autoimmune diseases. Additionally, students attend grand rounds conferences during their time on the rotation, including grand rounds in dermatology, rheumatology, and internal medicine, during which clinical case presentations and challenging diagnoses are discussed and new research advances are reviewed.
During the elective, students are encouraged to read from textbooks including Lupus Erythematosus: Clinical Evaluation and Treatment,17 Dubois’ Lupus Erythematosus,18 and Dermatological Signs of Internal Disease.19 They may also access primary literature sources using online resources available to them through HMS.
Institutional sponsorship and faculty
Drawing on the breadth of clinical and research resources available at HMS, multiple institutions and departments have been recruited to participate in this educational undertaking. Members from the Brigham and Women’s Hospital faculties in dermatology, rheumatology, neurology, and nephrology, as well as members of the Boston Children’s Hospital faculties in pediatric dermatology and pediatric rheumatology, welcome students into their clinics as part of this elective. Residents and fellows from the Harvard combined dermatology residency program, the Brigham and Women’s Hospital rheumatology/immunology fellowship program, the Boston Children’s Hospital pediatric allergy/immunology and rheumatology fellowship program, and the Brigham and Women’s Hospital dermatology–rheumatology fellowship precept students in the outpatient clinics and on the inpatient consult services.
Student requirements and performance
Medical students participating in the course are assessed in several ways. Direct observation of students performing patient care activities including both histories and physical exams, with particular emphasis on musculoskeletal and skin exams, allows for a thorough evaluation of clinical skills relevant to the management of patients with lupus. Faculty members also evaluate the medical students’ practice-based learning and improvement skills in their ability to obtain and apply research or scientific evidence to situations influencing patient care. The supervising residents, fellows, and faculty assess students’ understanding of therapeutic interventions and management.
Communication and presentation skills are also critically evaluated for each student, with particular attention paid to history-taking and physical examination skills as well as clinical case presentation skills. Additionally, given that the course is both interdepartmental and interdisciplinary, the student’s ability to participate effectively and professionally within a multidisciplinary team is assessed. All faculty members who interact with the students complete a written evaluation. Individual preceptors give medical students immediate feedback after each clinic session, and the course directors provide formal evaluation at the completion of the elective based on HMS evaluation and assessment standards.
By the end of the course, students must submit a final paper or lead a case-based presentation. Assessment of this final project focuses on the student’s ability to apply critical thinking to his or her work in addition to using knowledge and clinical experience gained during the rotation. Trainees must give an oral presentation of the final project to the course directors and other participants on the elective for successful completion of the rotation. Submission of final projects for scholarly publication or poster presentation is encouraged, and faculty provide guidance for such activities. At the completion of the course, standardized HMS course surveys are used to collect student feedback.
After completion of all course requirements, students receive an overall course grade in a format consistent with HMS registrar guidelines for elective rotations—namely, “high honors,” “honors,” “satisfactory,” or “unsatisfactory.” The grade becomes part of their medical school transcript. The course directors present verbal feedback to students on the final day of the four-week elective. The HMS registrar provides compiled written evaluative comments and a final grade to the student at the completion of the course. Longitudinal patient follow-up activities are not formally evaluated; however, throughout the remaining academic year, students communicate with one of the course directors (R.A.V.) after various follow-up visits with their patients. In addition, the students’ experiences are described in letters of recommendation requested for their residency applications.
Since the launch of the course in 2009, a total of 14 fourth-year students have elected to enroll in the elective. All students who have expressed interest have been given the opportunity to participate in this course. Feedback from students participating in the course has been positive. Student comments have identified the integrated nature of the course and the approach to coordinated disease management as particular strengths. Several selected comments from student evaluations are:
* “The first course I have participated in that allowed me to think about all aspects of a patient’s disease, including every organ system and the psychosocial burden of having a disease like lupus.”
* “An amazing exposure to comprehensive disease management with outstanding clinical and laboratory experiences.”
* “This elective truly allowed me to envision a career in medical dermatology, including not only understanding the systemic medications utilized, but also appreciating the close relationships fostered with patients.”
Suggestions for course improvements mentioned in the student feedback have led directly to modifications in the elective. For example, as a direct result of a prior participant’s suggestion, students now have the opportunity to present a challenging case from the rotation at grand rounds for discussion with multiple faculty and trainees. An additional modification to the elective arising from learner feedback is to have students follow a specific inpatient during the course to be able to track closely the patient’s in-hospital clinical course. Finally, to address the participants’ request to experience enhanced continuity of care and to understand further the impact of lupus on an individual’s quality of life as well as that of his or her family members, students now follow their patients longitudinally through clinical appointments during their final year of medical school. This has been a successful course modification. On the basis of our collective experiences designing, implementing, and gathering feedback from course participants, we urge other curriculum designers to include these changes at the outset of similar courses.
Of the 14 students who have completed the course to date, 4 have pursued residency training in internal medicine (29%), 6 in dermatology (43%), and 2 in combined internal medicine–dermatology residency programs (14%). The remaining individuals have pursued residency training in pediatrics (7%) and combined internal medicine–pediatrics (7%). During the same time period, 27% of all HMS students have pursued residency training in internal medicine, and 3.5% have pursued dermatology. Nationally, 22% of U.S. medical school graduates matched into internal medicine residency and 2% into dermatology during the same time period. Multiple course participants commented in postcourse feedback that their experience in “Understanding Lupus” had a meaningful impact on their residency selection.
Faculty impressions of the course have been extremely positive, with particular feedback on the opportunity to mentor students in an educationally integrative fashion. Notably, cross-disciplinary collaborations have been enhanced by working together to develop and consistently improve the elective’s curriculum. A novel monthly multidisciplinary conference has been established to incorporate the students’ final presentations. Moreover, patients who have been paired with the elective students have commented on their appreciation for having a medical provider “care about all aspects” of their disease and on their enjoyment in helping to educate future physicians about their experience with lupus.
Diagnosis and management of lupus remains challenging given the multitude of specialists often involved in a single patient’s care. Evidence suggesting a lack of concordance between how rheumatologists and dermatologists approach the care of patients with systemic lupus argues for multidisciplinary evaluation and management to provide effective, patient-centered care.20 It is our impression that early exposure of medical students to integrated management of a single disease enhances their clinical experience as they embark on their graduate medical education training. In our review of the literature on undergraduate medical education, we have not found any other published descriptions of courses focused on long-term conditions that are structured in a similar manner as “Understanding Lupus.” Whereas other courses on chronic diseases may use a problem-based learning model or a case-based discussion format, this course directly places students in the active care of such patients. Furthermore, “Understanding Lupus” blends the clinical experiences with a return to and integration of the basic science curriculum. To our knowledge, the course elective “Understanding Lupus: A Multidisciplinary Approach to Systemic Disease” represents a unique offering for fourth-year medical students to engage in a multi-institutional, multidisciplinary rotation dedicated to the exploration of a single disease process.
Connecting graduating medical students back to the basic sciences represents a challenge of integration and curricular innovations. A review of fourth-year course offerings conducted in 2007 identified that only 19% of U.S. medical schools and 24% of Canadian medical schools incorporate a basic sciences requirement for students during their clinical years.8 Educational approaches adopted by the medical schools include mandatory classroom-based seminars, elective rotations, and capstone courses. Recently described curricular innovations have also explored a similar reinfusion of basic science principles such as comparative physiology into internal medicine residency training.21
Curricular innovations in the final year of many medical school curricula have been lacking relative to other aspects of undergraduate medical education, despite recognition by residency program directors of this crucial juncture in the training of future physicians.22,23 Efforts are under way to introduce radically new approaches to medical education during this formative time, such as a recently piloted longitudinal program designed around a diagnostic technology—ultrasound—across multiple clinical specialties.24 On the basis of our experiences with “Understanding Lupus,” we believe that offering elective rotations to students that allow exposure to both clinical and laboratory experiences, as well as didactic conferences focusing on basic and translational research, is a particularly well-suited model for individuals making the transition from final-year medical student to first-year practitioner. Other conditions that rely on laboratory diagnostic skills and require the involvement of multiple medical practitioners for the management of systemic disease complications, such as diabetes and HIV, are chronic diseases around which similar courses may be constructed. Coordinated clinical approaches to multidisciplinary care in such settings offer opportunities to significantly enhance student learning.25 A key lesson learned from our experience has been the medical students’ enthusiasm for integrating basic science education in the elective’s clinical encounters, which echoes sentiments from our course planning focus groups.
The relatively small number of student enrollees to date in the “Understanding Lupus” course limits the broad generalizability of our experience. Currently, there has not been a formal assessment of the impact of this course on the patients involved in the longitudinal experience, though this remains a focus for us going forward. It is our belief that a longitudinal and multidisciplinary approach will allow students to enhance their learning experience and be better prepared for care delivery in an increasingly integrated health care delivery system. The need for further data and assessment to better understand the effect of continuity experiences on student learning and the impact on patients are also warranted.
The varied structure of fourth-year curricula across medical schools may pose challenges to the implementation of similar efforts at other institutions. We continue to solicit both student and faculty input and feedback on refining and expanding the course structure to meet the learning needs of course participants.
To date, the postcourse trajectory of participants in the “Understanding Lupus” course reflects a desire for those who enroll to pursue future training in fields related to the care of patients with lupus. Presenting students with a final-year elective to reinforce their clinical interests is an important mechanism to foster future clinicians dedicated to the care of patients with this complex and challenging disease. We hope this innovative educational undertaking may serve as a model for other multidisciplinary offerings across a spectrum of disease processes for the next generation of physicians.
Acknowledgments: The authors are grateful for the assistance of Mackenzie Leonard and Cathy Hounsell, the two course administrators.
1. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40:1725
2. Yell JA, Mbuagbaw J, Burge SM. Cutaneous manifestations of systemic lupus erythematosus. Br J Dermatol. 1996;135:355–362
3. Werth VP. Clinical manifestations of cutaneous lupus erythematosus. Autoimmun Rev. 2005;4:296–302
4. Chang AY, Werth VP. Treatment of cutaneous lupus. Curr Rheumatol Rep. 2011;13:300–307
5. Klein R, Moghadam-Kia S, Taylor L, et al. Quality of life in cutaneous lupus erythematosus. J Am Acad Dermatol. 2011;64:849–858
6. McElhone K, Abbott J, Teh LS. A review of health related quality of life in systemic lupus erythematosus. Lupus. 2006;15:633–643
7. Flexner A Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin No. 4. 1910 Boston, Mass Updyke
8. Spencer AL, Brosenitsch T, Levine AS, Kanter SL. Back to the basic sciences: An innovative approach to teaching senior medical students how best to integrate basic science and clinical medicine. Acad Med. 2008;83:662–669
9. Wagner EH. The role of patient care teams in chronic disease management. BMJ. 2000;320:569–572
10. Hulvat MC, Hansen NM, Jeruss JS. Multidisciplinary care for patients with breast cancer. Surg Clin North Am. 2009;89:133–176, ix
11. Hemmelgarn BR, Manns BJ, Zhang J, et al. Association between multidisciplinary care and survival for elderly patients with chronic kidney disease. J Am Soc Nephrol. 2007;18:993–999
12. To TH, Davies OJ, Sincock J, Whitehead C. Multidisciplinary care needs in an Australian tertiary teaching hospital. Aust Health Rev. 2010;34:234–238
13. Dewey J Experience and Education. 1963 New York, NY Collier
14. Bandura A Social Learning Theory. 1977 Englewood Cliffs, NJ Prentice-Hall
15. Bruner JS The Process of Education. 1976 Cambridge, Mass Harvard University Press . Rev. ed.
16. Harden RM, Stamper N. What is a spiral curriculum? Med Teach. 1999;21:141–143
17. Schur PH, Massarotti EM Lupus Erythematosus: Clinical Evaluation and Treatment. 2012 New York, NY Springer
18. Wallace DJ, Hahn BH, Dubois EL Dubois’ Lupus Erythematosus. 2007 Philadelphia, Pa Lippincott Williams & Wilkins
19. Callen JP Dermatological Signs of Internal Disease. 1995 Philadelphia, Pa W.B. Saunders
20. Grönhagen CM, Gunnarsson I, Svenungsson E, Nyberg F. Cutaneous manifestations and serological findings in 260 patients with systemic lupus erythematosus. Lupus. 2010;19:1187–1194
21. Herzig SJ, Aird WC, Shah BJ, McKernan M, Zeidel ML. From hagfish to humans: Teaching comparative physiology to internal medicine residents. Acad Med. 2012;87:372–377
22. Walling A, Merando A. The fourth year of medical education: A literature review. Acad Med. 2010;85:1698–1704
23. Lyss-Lerman P, Teherani A, Aagaard E, Loeser H, Cooke M, Harper GM. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009;84:823–829
24. Bahner DP, Royall NA. Advanced ultrasound training for fourth-year medical students: A novel training program at the Ohio State University College of Medicine. Acad Med. 2013;88:206–213
25. O’Keefe M, Burgess T, McAllister S, Stupans I. Twelve tips for supporting student learning in multidisciplinary clinical placements. Med Teach. 2012;34:883–887