Days after Yale School of Medicine (YSM) MD students received their white coats in the traditional White Coat ceremony, they engaged in a session entitled Opioid Use Disorder: From Bench to Bedside to Washington. On the same day that half of the incoming class participated in the session, a crisis was occurring on the New Haven Green less than one mile away; over the course of several days, there were more than 100 incidents of people poisoned by a blend of synthetic cannabinoids.
The opioid class was part of Introduction to the Profession (iPro), an eleven-day course that frames and launches students’ YSM curricular journey. The incident on the Green, and the critical role the local medical community played in responding, starkly demonstrated many of IPro’s objectives. Nancy Angoff, MD, MPH, MEd, associate professor of medicine and associate dean for student affairs, believes “iPro coinciding with the crisis on the Green could not have been more timely. It showcased the difficult issues the students will face as doctors, where they will be confronted with complex medical problems and complex personal interactions, including with patients and other health care providers, and how all these issues are impacted by societal issues like politics and economics.”
Additionally, she explains that “a central goal of iPro is to demonstrate to students, right from the start, how medical school is different from college. Students are no longer learning so that they can get an A and eventually get into a good medical school. They now are learning for themselves, so that they can take care of other people.” Rather than beginning medical school delving into the basics of the hard sciences, iPro includes topics such as professionalism, bias, identity, power, and privilege. It also provides an opportunity for students to spend time in the hospital and to meet active New Haven community members, including through tours of different city neighborhoods, so that students begin to engage meaningfully with patients and with their home city for at least the next four years.
Although opioid use disorder is a national issue, most medical schools are just beginning to build addiction medicine into their curriculum. Yale, with numerous leaders in the field, has been proactive on this front. This was the second year iPro included a session on opioid use disorder, and the first year that all incoming students attended the session; this is part of the broader effort to weave material about addiction throughout the YSM curriculum.
Stephen Holt, MD, MS, FACP, associate professor and associate program director of the Yale Primary Care Residency Program, who co-taught the opioid class, is an advocate for iPro, explaining “it is so valuable that right from the start of medical school, students are acquiring a big picture view of the human condition and are being exposed to the concept that the medical profession is not just about putting a Band-Aid on a problem organ, but instead is focused on prevention and using the respect given to health care professionals to influence public policy.” He believes this is “particularly important in a field like addiction, where medical professionals can play a key role in counteracting the pervasive stigma surrounding substance use disorders, and educate the public that using drugs is not a question of intelligence or willpower, but that it is a neurological disease, and therefore we should not judge people with the disease, but try to treat them. With drug addiction, the diseased organ is the brain; the organ responsible for making decisions.”
Holt decided to focus on primary care, in part, because primary care doctors have the opportunity to look at the whole person, which he believes “is critical to helping patients, since everything in life affects a person’s health.” Echoing an objective of iPro, he believes “medical students need to see that helping a human being isn’t just helping a symptom, they must take account of all the societal factors impacting their situation, ranging from their family situation to economic challenges they may face.”
Kenneth Morford, MD, an addiction medicine fellow who also did his primary care residency at Yale, co-taught one of the iPro opioid sessions with Holt. Morford told the students that in 2016, Connecticut had the 11th highest opioid overdose death rate of any state, and that faculty from YSM, including the Yale School of Public Health, are playing a leading role in Connecticut Governor Dannel Malloy’s data-driven and evidence-based Connecticut Opioid Response Initiative. He added “this is the kind of stuff you will be involved with now, as Yale medical school students.”
iPro coinciding with the crisis on the Green could not have been more timely. It showcased the difficult issues the students will face as doctors, where they will be confronted with complex medical problems and complex personal interactions, including with patients and other health care providers, and how all these issues are impacted by societal issues like politics and economics.
Nancy Angoff, MD, MPH, MEd, associate professor of medicine and associate dean for student affairs
While the poisonings on the Green had an impact on all YSM students, first-year student James Yoon had an individual experience on his eighth day at YSM, which also made many of iPro’s lessons and goals real and relevant. He was a few blocks from the YSM campus, when he saw a woman, who appeared to be physically unstable, standing in the middle of a busy street. Three women nearby had called 911, but had to leave, so Yoon offered to stay with the woman. Now that he was next to her, he could tell she was not only physically unstable, but confused, with slurred speech. She mentioned wanting to leave.
Yoon began speaking with the woman, both to gauge her level of confusion and to ensure she did not leave before a first responder arrived. He asked her if she had a safe place to go, drawing on an iPro instructor’s suggestion that this language was a more sensitive approach than asking someone if he or she had a home. While Yoon believes he would have tried to help the woman before iPro, he said his experience in the course gave him confidence and aided him with word choice.
After about five minutes, a police officer arrived and told Yoon that he had it under control. Yoon started heading towards home, but then decided to turn back to make sure the woman did not need additional help, “in part because of my gut feeling, but also because I was thinking about the discussion in an iPro session about what is meant by being a physician in the community and social responsibility.” He was carrying his white coat, which he had received the week before in a ceremony his parents traveled from South Korea to attend. He decided to put it on, thinking it might enable him to be a more helpful advocate for the woman.
When he got back to the scene, two EMTs had arrived, who told Yoon the woman had been in the hospital that morning. Yoon offered to go back to the hospital with her to help ensure she was receiving the care she needed, but the woman said she did not need help. Yoon encouraged her to seek help if she needed it, but “felt powerless as I said this, because I couldn’t tell her to go to the hospital and ask for me if she needed something, because I don’t have training or a role at the hospital.”
Feeling disconcerted, Yoon headed to the YSM Office of Student Affairs where he ran into Barry J. Wu, MD, FACP, who suggested that Yoon write about his feelings because this would remind him why we do what we do, when he is under pressure during medical school. Yoon, the first member of his family to attend medical school, appreciated this advice. He also appreciates that “iPro helped me think about what sort of physician I want to be, and how I want to help people to make a difference.” Yoon has lots of friends in their first year of medical school at peer schools, who immediately delved into the hard sciences. He is grateful that YSM is different, and that he now has a greater appreciation for the importance of mastering the hard sciences, so that in the future he will be able to help people not just as a human, but by using medical skills.