Giving medical students an early dose of clinical practice

Most people’s vision of going to Harvard Medical School doesn’t include getting birthday presents from your teacher, but celebrating birthdays is just one of the ways that Dr. Valerie Pronio-Stelluto makes her students feel energized about learning. Pronio-Stelluto, director of medical student education at Mt. Auburn Hospital, is one of several leaders of a course called Patient-Doctor II, which gives second-year medical students a taste of clinical medicine before they begin formal rotations at hospitals. The course directors employ several approaches to teaching, including using standardized patients and role-playing to familiarize students with patient interaction. For Pronio-Stelluto, an important part of teaching is to provide a safe, nurturing learning environment in which students can comfortably practice their developing clinical skills. With excellence in future patient care as the primary goal, she models the concept of "competence with compassion," validating students as important and encouraging them to help each other and play a proactive role in the curriculum design.

Following Dr. Pronio-Stelluto’s approach “see one, do one, teach one,” HMS students Susan Liu Hoki and Douglas Krakower demonstrate the Cardiac Exam to their PD II class during the Dresden faculty visit to Mt. Auburn Hospital

Now, some of the approaches of Pronio-Stelluto and the other course leaders at HMS are being used as a model for faculty at Carl Gustav Carus Dresden Technical University (TUD), who are hoping to integrate clinical experiences early in the curriculum and introduce new teaching styles. During a recent visit to Boston, several faculty members from Dresden observed sessions of Patient-Doctor II, which students at Harvard medical school take in their second undergraduate year. The course is part of the longitudinal Patient-Doctor series that begins in the first year of medical school, with the goal of introducing students to clinical practice and skill early on in their education.

From lectures to the bedside
Undergraduate medical education programs face a common problem: how to help students make the transition from the early years of basic science to its application in a clinical setting. HMS’ approach is to begin early developing bedside skills and working on several types of cases so that they are comfortable recognizing clinical problems and interacting with patients. Patient-Doctor II prepares students to perform a full physical exam; they begin by getting comfortable examining each other and eventually move to real patients.

The leadership at TUD has been working with HMI for several years to reinvigorate the curriculum at the school. They began by reworking the curriculum of the third and fourth years, which in the German system is a transition between basic science and clinical training. The Dresden faculty has incorporated case-based learning and tutorials in addition to lectures. They designed courses that integrate topics that were normally taught separately to be more clinically relevant, such as an integrated heart and lung course in which faculty from different departments work closely together on content. Now they are looking at new ways to approach the fifth year, during which students rotate through clinical block rotations at hospitals and attend lectures.

Creative approaches to clinical teaching
The goal of the visit was to let faculty from Dresden see HMS’ approach to bedside teaching, simulation, and longitudinal courses like Patient-Doctor. A group of faculty members from TUD visited Patient-Doctor II sites at several Harvard-affiliated medical centers: Mt. Auburn Hospital, Faulkner Hospital, Harvard Vanguard Medical Associates, Brigham and Women’s Hospital, and the Hebrew Rehabilitation Center for the Aged. Many of the faculty members appreciated the relative informality of classes like Pronio-Stelluto’s at Mt. Auburn, where students ask questions freely and often interact with faculty more than in Germany. Dr. Matthias Kirsch, a neurologist at TUD, also remarked that he was impressed with the time commitment of the faculty at the Faulkner Hospital and the organization of the class. “I liked the relatively structured and routine way the student presented their cases,” he added.

In a busy clinical setting, one of the ways to make sure students get the learning experiences they need is to create a more controlled situation than the standard hospital ward will allow. In the first two years of Patient-Doctor, instructors at HMS use a patient simulator, as well as actors portraying patients, and patients with specific problems, in order to focus on a particular disease or aspect of patient care. “The standard-patient impressed and surprised me most,” said Dr. Wolfgang Distler, a gynecologist at TUD, “especially that the patient gives advice to the students and is actually part of the exams.”

Dr. Valerie Pronio-Stelluto, center seated, and her group of Harvard medical students are shown with Mt. Auburn residents and faculty members from TUD on a visit to Mt. Auburn

Bringing new ideas to Dresden
There are some aspects of the HMS approach that would be difficult for the Dresden faculty to replicate: for instance, because it has affiliations with several hospitals rather than one dedicated teaching hospital, HMS is able to provide students with more access to clinical faculty than most schools, including TUD. But Dr. Cornelie Haag, an internal medicine specialist at TUD, felt that one approach the school should adopt is designating a single course director to oversee all the content, which is currently divided among different hospital departments. “At Harvard, the person responsible for the course is also responsible for the content,” she said. Adopting such a system would allow the faculty to “make sure that control of each part of the physical exam course is sufficient.” She would also like to devise a test similar to the OSCE test in the US, which would help identify which aspects of the exam are not being taught effectively.

Dr. James Warth, HMS lecturer on medicine and a site director for Patient Doctor II at the Faulkner Hospital, had some of the TUD faculty observe interactions between students and preceptors, and talked with them about curriculum design and educational approaches. Warth and his colleagues were also eager to learn about education in Germany. “They have a big agenda, and that was exciting,” said Warth. “They are committed; they honestly want to be a better medical school.”

The leadership at TUD will now work on ways to adapt their curriculum to include earlier clinical experiences and creative ways of teaching. Once they have revised some aspects of the later years of the curriculum, they will go back to the beginning—the first years of medical school, which in Germany are filled with basic sciences similar to undergraduate education in the US. By beginning to use problem-based learning in these early years as well, the Dresden team hopes to provide a fully integrated curriculum that reflects the needs of medical students today.

The following Harvard faculty participated in the Patient-Doctor II demonstrations: Dr. James Warth, Dr. Benny Gavi and Dr. Gary Brockington at Faulkner Hospital, Dr. Dara Lee at Brigham and Women’s Hospital, Dr. Zaldy Tan at the Hebrew Rehabilitation Center for the Aged, Dr. Valerie Pronio-Stelluto at Mt. Auburn Hospital, Dr. John Whyman at Harvard Vanguard Medical Associates, and Dr. Bill Taylor, director of the Patient-Doctor II program.