A new introduction to medicine

Last fall, Dervin Cunningham and a few of his classmates gathered around the hospital bed of a young woman who had complained of nausea and cramps. Before probing her health history, the first-year medical students politely asked the patient’s boyfriend to step outside. “We found out that she actually missed her period,” Cunningham said. A few more questions and the students offered their diagnosis: the patient, a female manikin at the Yale Center for Medical Simulation, was pregnant.

Under the medical school curriculum rolled out last fall, all first-years completed “Introduction to the Profession,” nicknamed i-Pro, during their first two weeks on campus. As she planned the course, said Nancy Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs, she emphasized activities in Yale New Haven Hospital (YNHH) and the New Haven community rather than in the classroom. Students would make rounds with nurses, physical therapists, dietitians, chaplains, interpreters, and social workers in the hospital. They would also visit the Errera Community Care Center and Columbus House, both centers for homeless members of the community. By immersing themselves in both the hospital and the community, students explored three themes: teamwork and communication, the patient experience of illness, and what goes into medical decision making.

Through patients’ eyes

During another i-Pro class, Cunningham stood near the bed of a patient—a real one this time—on the pediatrics floor at YNHH. He watched a doctor, an interpreter, and a patient’s parent exchange a flurry of information in English and Spanish. For another assignment, he crisscrossed New Haven on city buses with third- and fourth-year medical students. Patients treated at YNHH or area clinics might be staying at the Columbus House homeless shelter, Angoff said. If students experienced a small part of that journey and the shelter itself, they might become more empathetic doctors, she said.

“One of the most important things i-Pro did was encourage us to become citizens of New Haven,” said Andrea Roberts. “We can think of our time at Yale as the next stop on our way to Mass General, or we can really engage this community and give back to it—and we should try to do the latter,” said Roberts, whose visit to Columbus House was her first to a homeless shelter. The students learned how local physicians fought for and created a medical respite program at the shelter for patients well enough to be released from the emergency room but still in need of medical oversight. “Now I’m wondering how I can apply advocacy to my own career and if there are things I could do for women’s health,” Roberts said.

Uncovering biases

Before students arrived at Yale, they completed the online Harvard Implicit Association Test. Through i-Pro, students had a forum to discuss openly what the questionnaire revealed about how they viewed other beliefs, cultures, religions, ethnicities, and sexual orientations. They also discussed ways in which to address their preconceptions and implicit and explicit biases. “We want them thinking about how those biases shape the physician they will become and may affect their interactions with patients,” Angoff said.

At the Yale University Art Gallery, third-year student Robert Rock, who as a first-year had co-organized an elective course in health justice, helped them explore race, gender, and class issues through the observation of three paintings. In Whispered Words, an oil painting of a scene in Tahiti by Paul Gauguin, Rock explained that the image suggests a return to nature and simpler times. Historical accounts offer a different interpretation—Tahiti had long been colonized by the French and the artist exploited the native people. Another from the 1920s by the German painter George Grosz showed German high society at a lavish party, while outside their window a man on crutches holds out his hand for alms. “We can be primed to interpret reality in ways desirable to one group or individual, but detrimental to another,” Rock said.

Immersed in stories

Mark R. Mercurio, M.D., HS ’85, FW ’88, professor of pediatrics (neonatology), director of the Program for Biomedical Ethics, and lecturer in i-Pro, said it was no accident that i-Pro falls first in the new curriculum. “Very quickly, once school begins, students will necessarily be immersed in learning the language of medicine and the details,” Mercurio said. “It’s helpful to start with something that gives you some perspective about why you are here.”

The i-Pro course, said Roberts, now in her second year of medical school, “really showed me the bigger picture of what medicine is.”

Whether or not doctors realize it, Angoff said, they are enmeshed in patient stories. At the end of two weeks, Angoff asked students to reflect on their experiences during the course and put words to paper. She invited Anna B. Reisman, M.D., whose essays have appeared in Slate and The Atlantic, to discuss writing tips. Reisman, associate professor of medicine, is also director of the Humanities in Medicine Program. Lisa Sanders, M.D. ’97, HS ’01, associate professor of medicine, who writes the “Diagnosis” column in The New York Times Magazine, discussed how physicians benefit from keeping personal journals.

“We want you to be thinking about stories of the profession, both noble and shameful, the stories of your patients, the story of your community, and your own story as an emerging physician,” Angoff said.