Tagged medical schools

Reading Novels at Medical School

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Credit Getty Images

Sitting in a classroom at Georgetown Medical School usually reserved for committee meetings, we begin by reading an Emily Dickinson poem about the isolating power of sadness:

I measure every Grief I meet
With narrow, probing, eyes –
I wonder if It weighs like Mine –
Or has an Easier size.

It’s a strange sight: me, a surgical resident, reading poetry to 30 medical students late on a Tuesday night. Some of us are in scrubs, others in jeans; there are no white coats. Over the past four years, as the leader of the group, this has become my routine.

The students are here after long days in class and on the wards because they have discovered that medical education is changing them in ways that are unsettling. I remember that uneasiness well. My own medical education began with anatomy lab. The first day with the cadaver was unnerving, but after the first week the radio was blaring as we methodically dissected the anonymous body before us.

Two years later, on my first clinical rotation, I discovered that it does not take long to acclimate to the cries of patients as I hurried past their rooms, eager not to fall behind in a setting where work must be done quickly and efficiently. This practiced detachment feels necessary, a form of emotional and physical self-preservation. But with little time to slow down, ignoring our own thoughts and feelings quickly hardens into a habit.

During my first year in medical school, I found myself gravitating toward my old comfort zone — literature. As an English major, I had grown accustomed to the company of books and was feeling their absence now that “Don Quixote” had been displaced by Netter’s “Atlas of Human Anatomy.” I could look to Netter for concrete answers, but I needed Cervantes to help me formulate questions I had trouble pinning down, like why it was so easy to ignore the dead (and later, living) bodies around me? Illustrated cross-sections of the brain did little to illuminate the workings of my own mind. I needed time and space for introspection. The solution came in the form of a book club that later became an official course.

At Georgetown, the goal of our new literature and medicine track is to foster habits of reflection over four years of medical school. On the surface, the assigned books have nothing to do with medicine. We read no patient narratives, doctors’ memoirs or stories about disease.

Today’s topic is Haruki Murakami’s novel “Colorless Tsukuru Tazaki and His Years of Pilgrimage,” which tells the story of a depressed middle-aged Tokyoite’s attempt to retrace his past in order to understand how his life became so empty. We talk about the main character’s colorless perception of the world, and why his mind feels so inaccessible to us.

I receive an email from a student later that evening. He, an aspiring psychiatrist, tells me the story of a much-admired college mentor. “I heard last week that he committed suicide. I am still crushed,” he writes. “He was diagnosed with depression but seemed to be doing great.” If he so misjudged his teacher’s state of mind, he worries, how will he make it as a psychiatrist?

Earlier this year, we placed the ethics of animal testing under the magnifying glass of Karen Joy Fowler’s “We Are All Completely Beside Ourselves.” The novel is narrated by a woman whose “sibling,” we later discover, is a chimpanzee who was raised with her as part of a human-chimp experiment. We used the book to think through real-life examples like the Silver Spring Monkeys — a series of gruesome primate experiments that both galvanized American animal-rights groups and led to breakthrough scientific discoveries.

A third-year student talked about the three years he spent working with rhesus macaques. Research from his lab led to breakthrough discoveries about memory and behavior and contributed to therapies such as deep brain stimulation. “Doesn’t that answer the ethical questions?” he asked.

Another student talked about studies that she worked on for several years before starting medical school. “Have you heard of professional testers?” she asked the room. “People whose only source of income is volunteering for different studies, mostly college kids and immigrants? Shouldn’t we be talking about human research also?” For me, the discussion proved transformative. I walked into that class firmly supporting animal research and walked away still supporting research but no longer eating meat.

Our busy jobs on the hospital wards require precision and efficiency, but in literature class we can slow down and explore human lives and thoughts in a different, more complex way. The class is an anatomy lab of the mind. We examine cultural conventions and conflicting perspectives, and reflect on our own preconceived notions about life and work. Reading attentively and well, we hope, will become a sustaining part of our daily lives and practice.

As I’m walking out of the classroom at the end of the evening, a third-year student approaches me to tell me he’s been thinking more deeply about his experience of being an unrelated organ donor to his step-uncle, a man he barely knew. “It’s been on my mind since we read Ishiguro’s ‘Never Let Me Go’ last month,” he says. “I want to write about it. I don’t even know how I feel about it, and I need to figure it out.”

Daniel Marchalik, M.D., is a urologist in Washington and heads the literature and medicine track at the Georgetown University School of Medicine.

Giving New Doctors the Tools They Need

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Credit Early Wilson

They say if all you have is a hammer, everything looks like a nail. I wonder, then, why my toolbox often seems so inadequate for fixing my patients.

I open one recent afternoon in clinic with a middle-aged man I’ve come to know well. He’s drunk. His breath smells of alcohol and he slurs his words. He tells me his brother’s in jail, his mother died, and he punched a neighbor who tried to steal his wallet. In the past year, he’s been admitted to the hospital countless times for everything from falling to getting injured in a fight to failing to take his medications.

“High risk for readmission,” an automated email plops into my inbox each time he’s admitted. Thanks, I’m on it.

I search for mental health and substance use resources we haven’t yet exhausted. I speak briefly with a psychiatrist and case manager and a social worker who is arranging transportation back to the housing he’s in danger of being thrown out of.

“Maybe we increase his mood-stabilizer?” I offer, mostly just to say something. When all you have is a hammer…

The afternoon doesn’t get easier. I see a patient whose heart failure had been in good control with a telemedicine service that had checked his weight at home and adjusted his medications accordingly. But the service has been cancelled, and now he’s in our clinic, gasping for air as fluid fills his lungs.

He’s followed by an older man who’s been on opioid painkillers for a decade — and who I now suspect is selling extra pills on the street. I’m running 45 minutes late by the time I greet an understandably frustrated woman who, a computer alert informs me, is overdue for her first colonoscopy. She balks when I bring it up, and I don’t have the words or the time to convince her otherwise.

The afternoon was not unusual. At the end of most days, I find myself searching for nails that I can hammer.

Part of the problem is the tool kit we assemble during medical training. We’re educated largely in a biomedical framework. We diagnose disease with textbook knowledge and prescribe medications because those are the hammers we have.

But consider the skills I would need to be more effective in just this one clinic session: understanding social issues that contribute to health; marshaling support resources like case management, social work and rehabilitation centers; exploring my patients’ values and goals and encouraging behavior change; leading interdisciplinary care teams; employing new technologies and methods of patient engagement like telemedicine; and appreciating how health systems fit together to influence an individual patient’s care — from home care and community centers to clinics and hospitals. None have traditionally been emphasized in medical education — and, unsurprisingly, doctors in training like myself are often ill-equipped to practice in today’s health care environment.

Medicine has long been a discipline predicated on memorization, which made sense in a world of textbooks, microscopes and information monopoly. But rooting medical training primarily in knowledge acquisition is increasingly insufficient and inefficient. In an era of big data, Google and iPhones, doctors don’t so much need to know as they need to access, synthesize and apply. We’re increasingly asked to consider not just patients, but communities. We’re expected to practice not as individuals, but as team members. And now — liberated from carrying every diagnostic and treatment detail around in our heads — we have both the responsibility and the luxury of deciding what a doctor should be in the 21st century.

Some medical educators are trying to figure it out, with a greater emphasis on new technologies, collaborative care, wellness and community health.

The new Dell Medical School at the University of Texas, Austin, which enrolls its first class in June, is hoping to revolutionize medical education. The school plans to focus on helping students understand how health systems, communities and social issues contribute to individual health through a variety of innovative methods.

Instead of traditional lecture halls, Dell’s students will learn in collaborative workspaces with a curriculum that emphasizes team-based management of patients. They’ll take weekly classes with pharmacy, nursing, social work and engineering students. Dell’s “Innovation, Leadership and Discovery” program affords students an entire year to pursue projects related to population health and delivery system redesign.

Dell also features a unique collaboration with the university’s College of Fine Arts — known as the Design Institute for Health — to bring design thinking to health care. Here students will learn to think about everything from better hospital gowns and more hospitable hospital rooms to how patients access services online and how to make waiting rooms obsolete.

“It’s an incredible gift to start from scratch,” said Dr. Clay Johnston, the school’s first dean. “We can start by looking at where the biggest gaps and problems are. Then say, O.K., given those needs, what should doctors and the medical system look like in the future?”

The health system Kaiser Permanente recently announced its own plans to open a medical school in 2019, in Pasadena, Calif. The medical school, like the health system, will emphasize integrated care, the latest medical evidence and new technologies like online doctor visits.

“We recognize the importance of providing care in alternate settings,” says Dr. Edward Ellison, who is helping to oversee the creation of the school. “We’ll take care of you when you’re sick. But we’ll also help you stay healthy when you’re home.”

While most medical schools are trying to get students out of lecture halls and into hospitals, Kaiser Permanente hopes to get students out of hospitals and into communities. Students will visit patients in their homes to see how they live and what behavior change looks like in living rooms instead of hospital rooms. They’ll also be trained as emergency medical technicians — riding in ambulances alongside other medical professionals, responding to accidents, violence and trauma in their communities.

The American Medical Association, for its part, has provided over $11 million to established medical schools to reimagine their curricula and better prepare students for a rapidly evolving health care environment.

Older physicians, medical educators, policy makers and patients will continue to debate what doctors should be taught and what they should know. But the deeper question is how doctors can learn to think — to solve problems that can’t be solved with the tools we currently have. Because ultimately, there’s no better hammer than that.

Dhruv Khullar, M.D., M.P.P. is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

Should Doctors-in-Training Work Fewer Hours?

How many hours should medical residents work?

Hospital care is a 24-hour-a-day enterprise, but the question of which doctor should be there — and how long he or she should already have been there — is among the most controversial and unsettled in medicine. It’s a question that comes up almost daily among my peers, and my own feelings about the issue often depend on whether I’m trying to grasp details about a new patient or struggling to stay awake at the end of a very long shift.

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Dr. Dhruv Khullar

Dr. Dhruv KhullarCredit Tom Fitzsimmons

In 2003, at the genesis of the modern patient safety movement, the Accreditation Council for Graduate Medical Education mandated that residents work no more than 80 hours per week. In 2011, it limited individual shifts for first-year residents to 16 hours. Since then, research has been mixed on whether reducing the length of shifts or total number of hours worked has improved resident health, medical education or patient outcomes.

This year, two large national trials, known as iCompare and First, aim to shed new light on the issue. Researchers randomized first-year residents at internal medicine or general surgery programs across the country to work either 16-hour shifts, the current maximum, or longer shifts of 28 hours or more. Shortly after the iCompare trial began, two advocacy groups sent an open letter to the Office for Human Research Protections, calling the trial “unethical” and arguing that it exposes patients to dangerously sleep-deprived residents while exposing residents to a greater risk of car accidents, needlestick injuries and depression.

These trials come at a critical time, amid mounting evidence of serious mental health concerns for medical trainees. A recent study found that almost one-third of residents exhibit symptoms of depression; other studies show that almost 10 percent of fourth-year medical students and 5 percent of first-year residents admitted to having suicidal thoughts in the previous two weeks — with higher rates among minorities.

And yet, it’s not clear whether more restrictive work hours will make things better for residents or patients. When residents work fewer hours, there are more patient “handoffs” — when a patient is transferred from one doctor to another. The process makes it more likely that important details are overlooked, and intimate familiarity with a patient’s recent clinical course is often left behind. And residents may not even be reporting their hours accurately. Whistle-blower protections are lacking, and the penalty for work hour violations is loss of program accreditation, which could hurt the resident reporting the problem.

In the face of uncertainty, we need more data — and we’re starting to get it. Results from the First trial, published yesterday, found no significant differences in patient outcomes, resident satisfaction or educational quality when surgical trainees worked longer shifts. (Results from iCompare, which is looking at internal medicine residents, are expected in June.)

But I worry about how to interpret the results of trials like these, and what positive or negative findings may mean for residency training discussions going forward. In a profession driven by evidence, data is useful. But it’s important to recognize data’s limitations.

Many patient-care metrics we use to evaluate the impact of duty hour restrictions — mortality, procedural complications, adverse events, readmission rates — are crude. They might make sense for hospitals and health systems designed to increase efficiency and insulate patients from human fallibility. But they fail to capture the nuances of care delivered at the doctor-patient level. Good patient care is about more than surgical infection rates and medication errors. At the end of a long shift, am I the kind of doctor — and person — I want to be? Do I make time to sit with a suffering patient? Do I snap at a well-meaning colleague?

Well-being is similarly difficult to study. Research suggests that one’s judgment of happiness and life satisfaction is surprisingly fickle. For example, people interviewed on sunny days report being more satisfied with their entire lives than those interviewed on rainy days. So if you ask me about my training program after a particularly bad 16-hour shift, I’m likely to rate it worse than during a particularly good 30-hour shift.

Medical educators also worry that work hour restrictions force residents to see fewer patients and miss important educational experiences. At the same time, we allow residents to spend hours scheduling appointments, faxing medical records, gathering vital signs, obtaining prior authorization, and completing many other nonclinical tasks. We don’t learn to do these tasks in medical school; we shouldn’t be spending our time on them as residents. If we’re concerned about resident education, let’s focus on increasing quality time spent on direct patient care and educational activities.

The right answer on how many hours residents should work may be more nuanced than we’ve been willing to accept. It isn’t the same today as it was 20 years ago, as the complexity of caring for patients and medical technology continue to evolve. It varies by subspecialty — discontinuity may have graver consequences for neurosurgery, say, than for radiology. And it hinges more on the character of work than the length of it — I’d spend twice as long at a patient’s bedside if I could spend half as long at a computer.

Ultimately, the answer may be as philosophical as it is empirical. What kind of doctors do we want to be? What kind of doctors do patients want us to be? And does what we can’t measure still matter in a profession that’s now judged and motivated by what we can?

Dhruv Khullar, M.D., MPP is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.