Reinventing the Third-Year Medical Student

A year ahead in medical school, my friend had been a constant source of support and inspiration, offering study tips for courses and warnings about professors and, when he had neither, hilarious spot-on imitations of classmates and teachers. Patients he was beginning to see in his introductory course on the physical exam seemed to adore him, too; a few even wanted to set him up with their daughters.

“When we’re done with medical school and residency,” he always said, “we’ll be the doctors we’ve always dreamed of being.”

He stopped saying that during his third year of medical school.

One evening that year, I ran into him in the hospital cafeteria. The third-year schedule of rotating every few weeks among teams of doctors, trainees and real patients had left him gaunt. He showed me a stack of index cards, one for each patient he had been assigned in the last week.

“I got an ‘appy,’ a gallbladder and a breast biopsy,” he said, referring to patients with appendicitis, a gallbladder infection and breast cancer. He pulled out one card highlighted in yellow and smiled. “I also got a Whipple,” he said, referring to a patient with pancreatic cancer who needed that potentially complicated surgery.

“That,” he continued without flinching, “was awesome.”

My friend wasn’t the same. The patients had been reduced to their diseases.

For nearly a century, the third year of medical school has been a pivotal point in training, a crucial step in the development of professional skills and attitudes toward patients. Recently, however, the tradition of monthlong “rotations” – a speed-dating introduction to the major disciplines of medicine and the issues patients face – has come under fire.

During their third year, medical students are under constant pressure to perform for an ever-changing group of senior physicians, who in turn must evaluate the students based on brief interactions. Sailing through as many as six disciplines in just under a year, students have opportunities for only transient relationships, garnering mere snapshots of their patients’ illnesses and lives.

Not surprisingly, studies have shown that these experiences result in “ethical erosion.” Students’ sense of empathy and bedside manner deteriorate, and many begin to refer to their patients not as people but as diseases, that dehumanizing shorthand of the wards.

Now a growing number of educators are working to reinvent the crucial third year of medical school. A recent article in the journal Academic Medicine explains how one program has successfully eliminated traditional block rotations, promoting instead yearlong relationships between students and their patients and capitalizing on the patient-centered values and humanistic impulses that led the students to medicine in the first place.

Since 2004, the Harvard Medical School-Cambridge Integrated Clerkship has assigned every third-year medical student to a “panel” of up to 100 patients to care for over the course of the year. Students see their patients in the clinics of the Cambridge Health Alliance health system where the program is based, but also follow and assist with any outside consultations, admissions to the hospital, operations and even home visits. During the year, students are also required to shadow several assigned preceptors, senior physicians from the major specialties, in their clinics every week.

After offering this innovative third-year program for a few years, the organizers assessed the skills and experiences of the first students. They found that these students had more rewarding and humanizing learning experiences than their peers on traditional block rotations. And the positive effects continued to influence the students’ work even after they returned to the traditional track for the fourth year of medical school.

On standardized exams of knowledge and skills, most students from the new track performed as well as or better than traditional students, and many felt better prepared for clinical practice. On tests assessing important elements of care, these students were also better prepared to involve patients and their families in decisions, act in a caring way and deal with ethical issues.

“Our goal was to use the students’ idealism and altruism as a frame for their learning and mastery of the science,” said Dr. David Hirsh, lead author of the study and director and co-founder of the innovative program.

Some students followed their patients’ entire pregnancy and childbirth, then helped care for the baby. Other students were present for the entire course of a patient’s terminal illness, later becoming key figures in helping the family deal with that person’s death. One student who witnessed her patient being given a cancer diagnosis remained at that patient’s side through multiple complications that arose from treatment; the patient later attributed her survival to the constant and reassuring presence of her student.

“Patients have gone on to tell their friends about the program,” Dr. Hirsh said. “Now we are having difficulty keeping up with patient requests for their own medical student.”

The program also raises some significant challenges for educators and students. The commitment and level of guidance for senior physician preceptors is longer and more involved than usual. And students must deal with the intricacies of intense patient relationships, learning to set and communicate appropriate boundaries with patients.

Nevertheless, this program’s early successes add to what Dr. Hirsh calls a “growing movement” in medical education. Medical schools at Columbia University, the University of Minnesota, the University of California, San Francisco, and Harvard are strengthening their innovative programs, and more schools in the United States and abroad are poised to start similar ones. Dr. Hirsh and his colleagues are also examining how their approach influences student attitudes and skills years later, after graduation and during residency. The initial findings appear promising and may fuel further interest in this work.

“Good enough or even great enough can’t be our standard,” Dr. Hirsh said. “We need to allow medical students to be their fullest selves and to support their highest ideals of patient care.”