by Arabella Simpkin
In April 2014, the Harvard Medical School Cambridge Integrated Clerkship (CIC) reached its ten year anniversary. In celebration, national and international medical education leaders convened to reflect on the CIC in an educational symposium at the American Academy of Arts and Sciences in Cambridge, Massachusetts. The symposium was supported by The Dr. Ronald Weintraub Cardiac Surgery Research Fund of Beth Israel Deaconess Medical Center, The Arnold P. Gold Foundation, Cambridge Health Alliance (CHA) and the CHA Foundation.
Predictably, this milestone served as a moment to reflect. Indeed the opening framework for the weekend was a call to “look backward and look forward with curiosity and wonder.” Less predictable was the multifaceted and far-reaching discussion that followed. Two days of “think-tank” sessions stimulated, enthused, inspired, and gave hope that humanism can remain a core feature of the medical profession.
Longitudinal integrated clerkships (LICs) are rapidly growing in size, number and diversity both nationally and internationally and the Symposium’s audience reflected this multiformity. The think-tank sessions invited active discourse designed to “imagine the possible” and let “curiosity and wonder” abide. What could be the reach of the LIC model? What could be the next better model? Can medical education serve as a means of social repair? As one of the scholars at the meeting noted, “Thinkers and thoughts unbounded abounded.”
There is no doubt that transformation does not rest. And indeed should not rest. W. Edwards Deming remarked “It is not necessary to change. Survival is not necessary.” Right principles must be the formative force of change. For educational design, principles of educational science seem an obvious place to start. But these are not enough. For humanistic care delivery, other principles must also be named, actualized, reinforced and extended. Excelling at science and social justice, at clinical delivery and humanistic care, at the Institute for Healthcare Improvement’s Triple Aim and the universal call to “relieve human suffering” – these imperatives need deliberate design. Can longitudinal integrated education, based in relationships, animate these end goals? The assembled professionals weighed the data. The patients also had their views.
“She saved my life,” said one patient, describing her gratitude for having a CIC student — her “own student” who had been there throughout. The student who innocently challenged the initial diagnosis; who was able to “look outside the box” because she didn’t know where or what “the box” even was. “Like an angel” is the way another patient referred to her medical student. The patients viewed their students’ roles in their treatments not only as meaningful and memorable, but indeed as critical. Francis W. Peabody’s words to Harvard students in October 1925 seemed to come to life: “The secret of the care of the patient is in caring for the patient.”
The Cambridge Integrated Clerkship students echoed similar sentiments of gratitude for the impact their patients had had on their development as physicians. True symbiosis? Through the virtue of continuous relationships, the students felt they played authentic and meaningful roles. Students, like their patients, felt valued and appreciated. Duty and commitment, the students explained, guided their learning. Most importantly it seemed clear that their clerkship year had served to nurture and foster their humanistic impulses. “The informal hidden curriculum is their curriculum formalized,” said one national leader.
Strikingly potent was the description from another student that she intentionally used recollections of her clerkship patients to boost her through the challenging moments of residency and beyond. During those moments of low-morale and exhaustion it was these relational memories and her continued feeling of gratitude and closeness that served to propel her forward. This resonated with many in the audience, speaking volumes about the need for resilience grounded in humanism.
The anecdotal stories we heard, abundant in nature, from students, faculty, and patients left little room for doubt that the benefits of patient-centeredness seen in the immediate aftermath of the clerkship year prevail. Indeed, data suggests the same. A new paper by Gaufberg et al. demonstrates that LIC students maintained their patient-centeredness four to six years beyond completion of the program.
Undoubtedly any clinical education model needs to ensure that the medical scientist and the humane clinician are two threads tightly interwoven. Ten years ago the founders of the CIC hoped to begin a process that could drive medical education forward; they could not have imagined that this initiative would help renew energy for educational transformation not only across the nation, but worldwide as well.
It appears clear that when the patient is at the center of the student’s interest, and when those students are allowed to participate in meaningful ways, the humanistic impulses that attract so many into the medical profession burn brightly. With “curiosity and wonder” we now look forwards with high hopes and optimistic anticipation for the transformative changes in education yet to come.
Dr. Arabella Simpkin is a graduate of the University of Oxford and a Senior Pediatric Registrar in the London Deanery, UK. She is currently a Research Fellow in Medical Education at Cambridge Health Alliance and Harvard Medical School.