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Special Report: Doctoring Program Prepares Medical Students for the Real Deal

Scheck, Anne

doi: 10.1097/01.EEM.0000437836.92140.a4
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    It's an all-too-familiar story. She is 17 years old, and her future looks luminous. She's heading toward graduation without a hitch, holding down a part-time job at a local library amid a full academic schedule at school. But it's all work and no play for this teenager, laments her older sister, who beseeches her to go to a party. They can both just “get out and have some fun,” she tells her younger sibling.

    So the teen agrees to go. On arrival she spies a young man in the crowd of partygoers who also works at the library. They strike up a conversation, and he offers to give her a tour of the house. It has an old-fashioned charm, he explains, and is full of nooks and crannies. He subsequently ushers her into a corner closet.

    And it is there, in that dark space, that a violent and forceful act unfolds, just as he'd planned. Fearful and shocked, she succumbs without making a sound. And then, overcome by shame, she keeps her silence. It is only later, when she realizes that she is pregnant — pregnant but steadfastly opposed to abortion — that she decides to tell someone with whom she feels safe sharing the secret. She arrives at her primary care provider's office to do just that.

    The “doctor” in this case, however, is really a medical student at the University of California, Davis, and the teenager is not really a rape victim at all but an actress from a local theater group.

    This program, which began at University of California at Los Angeles more than 20 years ago, assigns small groups of students — seven or eight — to two faculty members one day a week for special training. Part of that training involves a case presentation like the vignette of the pregnant rape victim.

    The faculty pair generally consists of a primary care physician partnering with another health professional such as a nurse, psychologist, or pharmacist. Such faculty teams help medical students work on various key points during the sessions, including ethical issues and moral dilemmas in addition to medical ones. The program at UC Davis now draws not only medical students, but those from the law and veterinary schools as well as graduate students in social work.

    The program was founded by Jerome Hoffman, MD, a professor of emergency medicine at UCLA, and Michael Wilkes, MD, PhD, who was Dr. Hoffman's colleague at the time but now is director of global health care and a professor of medicine at UC Davis. When Dr. Wilkes left UCLA, he took the “Doctoring Program,” as the two call it, to the UC Davis Medical Center in Sacramento, and it has been part of the medical school curriculum there ever since. This year, Drs. Hoffman and Wilkes, along with two co-authors, published an article reflecting on its impact. (Acad Med 2013;88[4]:438.)

    Now, something like it — or may be something unlike it but just as bold — may be coming soon to a medical school near you, according to reports from the American Medical Association and the Association of American Medical Colleges. The AMA announced in January a $10 million grant initiative to attract “innovative projects to transform the way medical schools train future physicians.”

    AMA President Jeremy Lazarus, MD, asserted in a statement that the “health care of tomorrow” requires medical student training that teaches ways to foster a patient-centered, team-based approach to medical care, among other goals. A focus of recent annual meetings of the AAMC has also been the need for innovation in academic medicine.

    In fact, the AAMC took a long look at medical education needs in one investigation, and concluded that a more solid foundation in the behavioral and social sciences would benefit future physicians. (See FastLinks.) The association even created a contest that invited member colleges to submit a two-minute video forecasting how medical education might look in 20 years.

    Certain traits have been identified over the past few years as important to a new physician “professionalism,” including learning how to exercise resilience and adaptability under pressure (JAMA 2010;304[24]:2732); training in team interaction, including ways to rectify problems and resolve conflicts (Qual Saf Health Care 2009;18[1]:63); and education aimed at building skills that would enhance community and public health, which has been lacking in many programs. (Acad Med 2010;85[2]:211.) The latter is particularly pressing because as of 10 years ago researchers began systematically documenting the continual rise of new vector-borne diseases worldwide, as well as that of childhood obesity with all of its health complications. (Science 2003;302[5652]:1898.)

    The call for change is being linked to the sweeping reforms recommended in the “Flexner Report,” a document that celebrated its centennial four years ago. A pioneering former school administrator, Abraham Flexner, published in that century-old analysis observations about medical education gleaned from study and travel in Europe. His conclusions — that curriculum should be standardized and scientifically based and taught by teachers steeped in the profession — revolutionized physician training.

    “The middle path cannot be trodden,” he said, because the stakes are too high, involving sick people who bestow their trust upon those educated to proffer them care.

    The Carnegie Foundation for the Advancement of Teaching, alluding to the anniversary of the Flexner Report, recommended revisions to current medical education; more emphasis should be placed on individualizing the learning process for medical students and residents and promoting more “habits of inquiry” among them, along with measures that would help standardize these efforts. (Acad Med 2010;85[2]:220.)

    The traditional culture of medical school in which students tiptoe in a high-wire act and learn to be confident rather than probative still exists, Dr. Hoffman said. “I can't imagine any better way to stifle learning than to make people afraid to ask questions,” he said, noting that he has seen this happen time and again. “Students may be afraid to ask not merely because they don't want to acknowledge that they don't know something their peers seem to know and thus admit that they are themselves inadequate, but also because they may be afraid any questioning will be interpreted as challenging authority.”

    This is the atmosphere into which Drs. Hoffman and Wilkes took the new program on “doctoring” those many years ago. The course sessions typically kicked off with a check-in like, “Let's just all talk about what's going on in the wards,” Dr. Hoffman said. Everyone got to know each other very well, creating an unusually “safe group” for discussion and debate, he said. Usually, this initial hour was followed by presenting a true-to-life case, with one of the students serving as the physician. Patients and patients' family members were portrayed by actors.

    “It was easy to get really good ones here in Los Angeles,” Dr. Hoffman observed. An actor posing as a distraught father, for example, might become disruptive or emotional while attempting to find out whether his son's worrisome behavior might be caused by a drug habit.

    The medical student “doctor” of the day or a faculty member could call a time-out at any point to ask for feedback from fellow students or the faculty. This would prompt discussion from everyone except the actors. “They were under orders to stay mum,” Dr. Hoffman explained. Bantering back and forth, exchanging ideas and arguing solutions proved to be “a very Socratic environment,” he said. “We were asking everybody to think.”

    The course was mandatory for the first three years and voluntary the next when fourth-year students could return as “fellows,” and a majority of them did so, Dr. Hoffman said. “In the first year, I was bending arms to get students to return for the fourth year; now there are more than 60” of about 100 students who want to sign up, Dr. Wilkes said.

    Such a program challenges medical students with problems they will face in practice: the patient who has had a previous misdiagnosis, the angry patient, the one who is noncompliant, the patient who asks questions the doctor cannot answer, the elderly patient who is confused, the one grieving over the loss of a family member, the patient from a different culture who expects an approach that is radically different from the norms in Western societies. “It's a lot of work.” said Dr. Wilkes. “And it's a lot of fun.”

    Some students found the course difficult, Dr. Hoffman acknowledged, because rather than helping them be “efficient” in addressing all the many things they needed to learn, it asked them “to spend time thinking about what they were being taught and even to challenge what they already knew.”

    No solid numbers exist on how many such programs there are, in large part because no two seem to be wholly alike. But some medical schools have built critical-thinking assessments into their educational process. They were formed, at least in part, to ensure safety isn't just a top consideration but also an outcome from habits of thought, noted Pat Croskerry, MD, PhD, a professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia, and a founder of a singular program there that tracks students' progress in achieving the skills for good decision-making.

    Support is growing for changes that would put more emphasis on thinking capacity and human interaction, agreed James Feldman, MD, a professor of emergency medicine and the vice chair of research in emergency medicine at Boston Medical Center. He warned in an interview this past spring that the potential is higher for “asynchronous care” without such changes.

    One barrier is the variability in interpretation and implementation of programs to promote critical thinking; metrics can be hard to come by. When studies employing feedback techniques in medical education are compared, for example, there's an apples-to-oranges problem not easy to overcome. (J Eval Clin Pract 2013;19[2]:230.) The trick is to “find the right and effective format and ensure that the culture is appropriate,” said Elaine Larson, RN, PhD, an associate dean of research at Columbia University, who has evaluated the influence of feedback on infection control and other factors involving compliance.

    The emphasis on feedback over the past 10 years gave rise or at least coincided with the growth of simulation. Both approaches require monitoring and critique. Simulated patients — individuals carefully trained to portray an illness based on an actual case — have been used fairly routinely to teach medical students about the three Ds: disability, disease, and drug effects. More recently, actual patients have been utilized, ranging from those who are recovering from addiction and can give a realistic appraisal of that challenge to geriatric patients who can field questions about old age and its health toll.

    People with disabilities in Boston and other institutions have been part of two medical training simulation programs, and the “rewards for everyone involved are substantial,” according to the results of one study. (Acad Med 2011;86[9]:1163.) The same was true when one medical school used teenagers — actors from a local high school — to role-play various conditions. But the teens also were told to include their own personal reactions and impulses during the sessions to give a clearer picture of the adolescent viewpoint. (Med Educ 2001;35[3]:206.)

    Dr. Wilkes said nothing can substitute for this experience. “When I run into former students at airports or train stations or wherever, they always tell me, ‘When I look back on medical school, the thing I remember most, and what I think I got the most from, was the doctoring course.’”

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