A new approach to clinical clerkships

On the ninth floor of a building on George Street, in the School of Medicine’s psychiatry department, third-year medical students gathered for a Thursday afternoon class in the fall of 2015. Portraits of august professors looked down from the walls as the students trickled into the conference room, swapping notes, napkins, and silverware while they opened their lunches. MacBooks and iPads came out as the minutes ticked by until Peter J. Ellis, M.D., M.P.H., assistant professor of medicine, stood at the front of the room. He was there to discuss case studies of lower back pain.

Lower back pain in the psychiatry office? What gives? An hour and a half later, Ellis and his co-educators stepped to the side, and Beth D. Grunschel, M.D., Sc.M., assistant professor of psychiatry, then a fellow in the addiction psychiatry program, took over. She offered behavioral change as a management plan for chronic pain instead of prescription painkillers. Students divided into pairs to role-play patients consulting doctors about their chronic pain. “Figure out a way to do a little less talking and make him talk instead,” Grunschel advised one “doctor.” At the conclusion, she counseled the group. “It’s practice. You’re going to have a lot of patient interactions that aren’t going to go well. You’ll learn how to phrase it.”

Mental health and primary care would seem like an unusual combination at first blush. Across the country, when medical education combines disciplines, usually primary care and internal medicine are paired together—leaving psychiatry joined with neurology. But primary care doctors often see cases of depression and anxiety in their routine practice; and at Yale, an early spotlight on this type of multidisciplinary question will soon become routine.

Cross-discipline integration is a hallmark of the new curriculum being rolled out in the School of Medicine—particularly in the third-year clerkships, when students traditionally begin their hands-on experience with patients. “We recognize that patients have symptoms that can be addressed in many different disciplines,” said Kirsten M. Wilkins, M.D., FW ’06, director of the YSM clerkship curriculum and associate professor of psychiatry as well as director of the psychiatry clerkship. “Being able to integrate all of that from the student standpoint will hopefully be more effective for them.”

Julia Raney, then a third-year student in the primary care and psychiatry clerkship, found it helpful in her own rotations. “It’s a good emphasis,” she said. Near the end of her primary care rotation following her rotation in psychiatry, Raney saw a female patient. “Her chief complaint was anxiety. It was so interesting to think about all the treatment that might be expected for her; what stressors; what other mental health conditions she might have that I should look for; how I should structure the interview. I was falling back on the skills I had just gained.” While the length of traditional primary care appointments is often much shorter than appointments in psychiatry, Raney said that patients in primary care often had mental conditions affecting their lives: “It made a lot of sense to me why they combined these two. You’ll need to know psychiatry in every field you go into.”

Starting the clinical experience

All 104 third-year students gathered on June 15, 2015, for a daylong series of activities to prepare them for the clerkships to come. The orientation focused on integrating science, professionalism, and clinical care. Students toured the Yale Center for Medical Simulation to practice technical procedures (see sidebar), and participated in an interactive session on how to give and receive feedback during their clerkships. Over lunch, they heard from health care professionals about the types of hospital personnel they would soon encounter. The following day, the students divided into their respective clerkships—but unlike previous years, in which students were sent to one of 10 different clerkships, students train for 12 weeks at a time in four integrated clerkships.

Previously, 10 clerkships meant that students spent only two weeks in some specialties and up to eight weeks in others. They moved rapidly among patients, teams, and disciplines, and their experiences varied widely depending on which types of patients they saw. The School of Medicine is moving to a system of integrated 12-week blocks, allowing the students longer and more predictable clinical experiences. While third-year students always began their clerkships in June, under the new curriculum clerkships will begin in January. This change will give students more flexibility to pursue subinternships, electives, and research after the clerkship year.

Whittling down 10 separate clerkships into four integrated modules also streamlined the educational material. The clinical year now comprises “Medical Approach to the Patient,” bringing together training in internal medicine and neurology; “Surgical Approach to the Patient,” including surgery and emergency medicine; “Women’s and Children’s Health,” focusing on pediatrics and obstetrics and gynecology; and “Primary Care and Psychiatry.” Anesthesiology has morphed into an elective within “Surgical Approach to the Patient.”

Each block unites two disciplines that share aspects of their approach to patient care. “The integrated model forced us to really reevaluate our curriculum,” said Wilkins. “We had to think about the essential psychiatry experiences that students need to have. It forced us to critically evaluate every element of what we do. We’ve had some exciting debates.”

Not every student progresses through the clerkships in the same order, but over the course of the year, all the themes cover critical material. For example, in the primary care and psychiatry clerkship, students focus on health promotion, preventive care, the social determinants of health, behavior change, and chronic disease management. This lineup contrasts with the “Surgical Approach to the Patient” clerkship, in which students learn emergency management and operating room procedures. While there may be some overlap, the themes are meant to provide direction, reinforced in the weekly didactic sessions, to students as they progress.

Didactic sessions emphasize the themes for the students more directly, as with the psychiatry conference on lower back pain. The integrated series includes case-based learning and reasoning workshops. “When you bring students together for these shared didactics, they can look at how two disciplines approach the care of the patient, and they can better understand the patient’s experience as well,” said Richard Belitsky, M.D., HS ’82, FW ’83, deputy dean for education, in a faculty presentation during an internal medicine departmental meeting. That patient experience, Belitsky explained, is critical for students to grasp—a patient often sees multiple doctors from different disciplines. “This is a chance for students to come together and see: what each specialty contributes, and when a discipline decides to consult with another discipline? And when they do, what actually happens, and how does that affect patient care?”

Between each of the 12 clerkship weeks, all third-year students also come together for one day of interactive sessions as part of a developmental curriculum. These group sessions continue to build the students’ skills in communication, professionalism, and teamwork. And at the beginning of each new integrated clerkship, students go through a one–day “boot camp” to help them prepare for more discipline-specific experiences and refresh their background knowledge. “It is a lot of information,” said Wilkins, “but I think everybody has done a really good job of making it concise and high-yield instead of belaboring any one point for two hours.”

Wrapping it up

Throughout the clerkship year, students are asked to reflect on their personal education; any distressing experiences with their clinical teams; and ways to improve the program. The curriculum steering committees often included third- and fourth-year students during planning to help ensure the best possible outcomes. Wilkins commented, “I did hear one of our senior students on our committees say that she wished she could go back and do her third year [in this new model]. Several of us faculty members have also said we want to go back to medical school. We are really excited by the changes.” As recipients of the first rollout from the larger curriculum revamp, the clerkship students’ feedback will be critical—and when asked how it feels to be among the first students in the new program herself, Raney answered, “We’ve learned on the fly.”