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Passing of the torch in clinical skills education

Yale Medicine Magazine, 2014 - Autumn


A Greek inscription carved into the stone face above the entrance to the Sterling Hall of Medicine translates: “Those having torches will pass them on to one another.”

“It’s something Plato said,” said Margaret J. Bia, M.D., FW ’78, known for her tenacious personality, her Brooklyn accent, and her contributions to the clinical skills education of more than three decades of School of Medicine graduates. According to Bia, the clinical skills program, with approximately 140 faculty members who educate the next generation of physicians, exemplifies the value extolled by Plato. This year she’s passing on the torch.

Bia is retiring from medical education, though she’ll continue as a senior transplant nephrologist at Yale-New Haven Hospital. Jaideep S. Talwalkar, M.D., HS ’04, assistant professor of medicine and of pediatrics, will take over just as the medical school prepares to implement a redesign of the curriculum. Talwalkar will direct the clinical skills program at large, ultimately determining how it will fit into the new curriculum that emphasizes early clinical experience, an integration of the basic sciences and clinical medicine, and a restructuring of the clerkships. “With the curriculum redesign, we’re going to have to remake what the clinical skills program looks like,” said Talwalkar.

Barry J. Wu, M.D., clinical professor of medicine, will run the clinical tutor program.

Bia has been the face of the clinical skills program at Yale for the last 15 years. When she took over in 1998, the program was heavy on didactics and light on practice, but under her leadership that all changed. “Dr. Bia has really changed the landscape entirely,” said Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs.

Historically, the first two years of medical education at Yale had focused on the basic sciences, and until the 1980s, clinical skills education began at the end of the second year. Students’ only clinical training before then was a physical diagnosis course. In the 1990s, faculty added sessions on interviewing and patient communication, and started the tutor program. Today, clinical skills education begins before students even arrive at Yale, with the psychosocial communication curriculum run by Paul D. Kirwin, M.D., associate professor of psychiatry. Essays that students write during that curriculum influence the content of the clinical skills program, which is overseen by Barbara Hildebrand, the program manager.

Bia arrived at Yale in the mid-1970s as a transplant specialist. Teaching had always come naturally to her, but she never imagined that she would have a seminal role in the formal education of medical students. Her love of medicine and doctoring led Bia to grow the clinical skills program into what it is today—a program that includes 44 skills sessions and 44 clinical tutorials in the first two years, 10 additional sessions for advanced skills training in the third and fourth years, a tutorial program, and sessions on LGBTQ issues, hospice, observation skills, and more.

“The skills program is very much where [students] learn the art of medicine,” Bia said. Much of that learning takes place in the tutorial program, in which a seasoned physician partners with four incoming students. Bia expanded and standardized the weekly tutor-student meetings that take place throughout the first and second years, ensuring that students and tutors get the most out of each session by outlining the goals and objectives.

According to Wu, the mentoring relationship between students and tutors sets Yale’s program apart. “The longitudinal relationship is something that’s really celebrated here,” he said.

“I always wanted Yale to be as known and famous for medical education as it is for science and research,” said Bia. She assembled a dream team of clinical educators that created the program as it is today. “It is not my program—it is the team’s program,” said Bia.

Auguste H. Fortin VI, M.D., M.P.H., associate professor of medicine, was teaching patient-centered interviewing skills to primary care internal medicine residents when Bia invited him to do the same for medical students. Patient-centered interviewing allows physicians to obtain biological, psychological, and social information and to create a more holistic description of a patient. According to Fortin, it can increase diagnostic accuracy as well as professional satisfaction among physicians, and decrease the risk of burnout and malpractice suits. “I think there’s a rich tradition of humanistic care at Yale, and it was part of the informal curriculum,” said Fortin. “[Dr. Bia] brought it front and center into the formal curriculum.”

To further improve physician-patient communication skills, Bia brought on Matthew S. Ellman, M.D., associate professor of medicine. Ellman, director of Medical Student Palliative and End-of-Life Care Education, teaches the students how to communicate with patients at the end of life. “This isn’t considered one of the traditional medical skills, like taking a medical history or performing a physical exam, but she recognized that this is a skill that all medical students at Yale should get before they graduate, because no matter what specialty they go into, they’re going to, from time to time, be faced with patients that they can’t cure,” said Ellman.

“There’s something that’s just Dr. Bia that you can’t replace. You can’t really describe how much she cares about the program, but you can tell how much she cares about it,” said Samuel Sondalle, a third-year M.D./Ph.D. student. “The success of the program is reflective of that.”

Talwalkar hopes to build upon that success in the program in the future by beginning clinical learning even earlier, getting residents more involved in medical student teaching, and having students work within interprofessional care teams. “I don’t look to be replacing [Dr. Bia] in any way,” said Talwalkar. “I look to be building on what she’s already put in place.”

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