Patient-Centered Longitudinal Experience

Can we teach medical students by teaming them up with patients?

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Joyce Tang talking about the patient-centered longitudinal experience.

[00:00:12] Dr. Tang: They may go with the patients to the primary care physician office, they may go to a specialty visit. I've had students go to dialysis sessions or to physical therapy sessions, they're seeing patients in the hospital. I've even had students that have gone to the operating room.

[00:00:35] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Joyce Tang. Dr. Tang is an associate professor of medicine and comprehensive care physician in the section of hospital medicine at the University of Chicago.

Her clinical work is devoted to providing longitudinal primary care across inpatient and ambulatory care settings for a panel of patients with high health needs and frequent hospitalizations. She leads qualitative research efforts for the Comprehensive Care Program, with a focus on patient perspectives and preferences related to care, the patient-doctor experience, and reasons for variation in patient response to the program. She also developed and leads an educational program called the Patient-Centered Longitudinal Experience in which first-year medical students are partnered with patients with complex chronic disease with whom they co-navigate clinical care experiences across multiple settings.

Joyce is a graduate of the Pritzker School of Medicine at the University of Chicago and an associate junior faculty scholar in the Bucksbaum Institute. Thank you so much for joining me today.

[00:01:51] Dr. Tang: It's a pleasure to be here. Thank you.

[00:01:53] Dr. Cifu: So I mentioned the Patient-Centered Longitudinal Experience or PCLE as I guess we call it, in the introduction. Can you just tell me about the program and kind of what led you to develop it?

[00:02:06] Dr. Tang: Yeah, absolutely. So the idea for the program really started from the observation that a lot of medical education traditionally is from the physician's perspective. It's led by physicians and necessarily comes from the physician's point of view. I think there's a lot of advantages to that and I think it's appropriate in so many ways, but if we're really wanting to develop patient-centered physicians, I don't think that that's enough. So what is really needed to develop empathy and patient-centered attitudes is a better understanding of the patient's experience of illness and their challenges, I think, that they face in navigating the healthcare system.

[00:02:46] Dr. Cifu: And so tell me about the program itself. I know that students are kind of paired up with patients, and then the students actually just go to visits with the patient, is that kind of the gist?

[00:02:59] Dr. Tang: Yeah, so before I tell you about the program itself...

[00:03:02] Dr. Cifu: Yeah.

[00:03:02] Dr. Tang: ...let me tell you about the traditional kind of experience. So we embedded it in our longitudinal program, which is traditionally that kind of first-year medical student clinical preceptorship experience. And so...

[00:03:13] Dr. Cifu: The response to students always saying, "We want to be in the clinics as quickly as possible!"

[00:03:17] Dr. Tang: That's right, that's right. And so, you know, that traditional experience is the student paired with a physician preceptor where they see patients with the physician preceptor in the single clinic setting over a longitudinal period of time.

[00:03:32] Dr. Cifu: Right.

[00:03:32] Dr. Tang: And so this idea is actually quite simple. So it's taking that model but adding to it two additional patient partners.

[00:03:41] Dr. Cifu: Got it.

[00:03:41] Dr. Tang: And so the experience for the student then is that they are working with these patient partners over a variety of settings over a longitudinal period of time. They may go with the patients to the primary care physician office, they may go to a specialty visit. I've had students go to dialysis sessions or to physical therapy sessions, they're seeing patients in the hospital. I've even had students that have gone to the operating room to see their patient, you know, pre-op, during the operation, and post-op. So it can be quite diverse in terms of the experiences.

[00:04:15] Dr. Cifu: And so these students get a much more diverse experience because instead of just only say, you know, working with, I don't know, a geriatrician, seeing only an older set of patients coming to appointments, these students may see multiple different kinds of doctors doing multiple different kinds of things in multiple different settings, right?

[00:04:35] Dr. Tang: Absolutely. There is bigger variety, they see different styles of care. They see their patients over time, importantly, really kind of having different types of communication with different physicians. They also get to see what happens, I think, to these patients between visits after hospitalization that others don't see in terms of how do they really fit their illness and the management of it into their daily lives.

[00:04:58] Dr. Cifu: Do you... I was going to ask you sort of, you know, what you hear from students about what they learn and about the challenges in the program, but maybe I'll start specific and then go general. You know, I always think when students make their way through medical school, right? They see a lot of different physician styles, right? And I think we always tell students, like, "Pick the ones which seem like they're good and they're going to work for you and try to ignore the bad role models. Maybe just the ones that are wrong for you." The students are seeing doctors in a different way here, right? Because they're more on the patient's team than on the doctor's team. Do you feel like or do students tell you that they get more of a sense of different physicians' styles in this setting?

[00:05:42] Dr. Tang: They definitely do. I mean, I think that when we have a course, like the Longitudinal Program, which this is embedded within or was embedded within, we have a select group of preceptors that are specifically chosen for their communication style, their interest in having students there, and a holistic perspective, you know, for early learners. When we send students into a busy clinic, you know, where perhaps a preceptor or a physician who's practicing is not necessarily signed off to do this kind of work, it's a little bit different. We definitely ask students to email ahead, notify that they're coming. So there is that, and you know, it's interesting to see what happens when they show up, right? The patient will be, "These are my bodyguards, this is my team." And so it's a bit of a different interaction there. And I think that oftentimes it's a very positive interaction. As with any clinical encounter, sometimes it's not positive and they have seen things and they've seen things slip through the cracks and, you know, I think then those are opportunities to discuss with their preceptor, "You know, this is what I saw. I have questions. You know, how do I process this?" It's a little bit of a different interaction with your physician preceptor. I think a lot of medical education, you're used to precepting face to face in a dedicated clinical session, but this really requires preceptors to do that precepting and kind of be guiding students outside of that setting. And so there's some proactivity that's required on both sides.

[00:07:12] Dr. Cifu: Do you ever hear from patients that their experience with doctors change, you know, having a student in the room?

[00:07:20] Dr. Tang: I think that patients really love this.

[00:07:22] Dr. Cifu: Yeah.

[00:07:22] Dr. Tang: They really do. I've had students kind of prepare patients before their visits about what are you going to talk about and they've prompted patients in their room who maybe didn't want to bring something up that they had brought up to the student, so I've had that happen. I've had... I think generally patient feedback is just, "Wow, somebody is here. They're listening to me. They're taking the time." And I think it gives them a sense of purpose...

[00:07:49] Dr. Cifu: Yeah.

[00:07:49] Dr. Tang: ...and meaning.

[00:07:51] Dr. Cifu: It's interesting because I mean, clearly, the reason for this is for medical student education, but you sort of are throwing a patient advocate into the room.

[00:08:00] Dr. Tang: Absolutely.

[00:08:00] Dr. Cifu: And that advocacy, I'm sure, develops over the time that the student is with a patient and becomes closer to them and knows them.

[00:08:07] Dr. Tang: For sure, for sure.

[00:08:09] Dr. Cifu: Challenges? You know, are there things that are often difficult for the students or, you know, maybe things that you think they're not quite ready to be exposed to since you're getting students really at the beginning of medical school for this?

[00:08:23] Dr. Tang: We are and there definitely are challenges. I think the primary one is somewhat logistical. So as you know, patient appointments can be scheduled at any time of day, any day of the week, depending on the physician's schedule and the patient's schedule. That may altogether be not the time that students are available outside of class. So that might not work out. Also, and more importantly, I think that patient appointments are often canceled or rescheduled for a variety of reasons, and sometimes patients can't make it to an appointment. They might have transportation issues or whatnot. And so that does sometimes cause some frustration, right? For students.

We've heard some students be quite frustrated, you know, that, you know, they have the expectation I think that with their classes, there's a set time they come in, it's high-yield, and sometimes when this occurs, I think it's very difficult for them. And I think students can take it in one of another... A couple of different ways, right?

So we've noticed that the student dissatisfaction seems to happen more when they didn't self-select into the program. So when they elect to do it, which is kind of the way we do it now, because we have more interest than we can accommodate, it's not a problem. I think students roll with it and expect it.

[00:09:36] Dr. Cifu: I'd love to know, and this is generalizing a little bit, definitely, and dichotomizing a little bit, you know, there are the students who get to the third year, the kind of traditional clinical year, and they are the students who very quickly sort of fall into the role that, you know, "Look, we're here to provide care. I understand that I'm going to learn in that providing of care and I'm going to get some focus teaching, you know, when time allows." And then there are students who are kind of put off by our current clinical education because, you know, they're used to college in the first two years, where kind of everybody's there to teach them. It's not that they're the center of attention, but the focus is on education, which is absolutely not the case in any clinical experience. So it'd be interesting to know, you know, if what you're doing to some extent is prepping students for that like, practice-based learning that happens not only later in medical school but ideally happens in the rest of their careers.

[00:10:32] Dr. Tang: I think you're right, and we do get tremendous insight into the professionalism, which is really important for students. I think that they have to be much more self-organized and motivated. We ask them to check EPIC regularly because appointment times may change. So instead of you show up, you know, every fourth Thursday to your preceptor's clinic, and they will kind of shepherd you through the visit, you're kind of on your own. You got to navigate, you got to... Things may come up and there isn't necessarily someone there all the time. So with great responsibility comes... With great kind of challenge I think, there's autonomy, I think you do need more kind of responsibility. So I do think that it does help in that direction.

I also think that as early medical students, they do still require quite a bit of supervision, you know? And I think that, you know, we ask students to call patients, you know, sometimes to check in on them or they go to visits without the preceptor. I think that those are great opportunities, but I also ask them specifically to send a message to their preceptor every time they have an encounter with a patient, whether they think it's important or not, whether they have a question or not, to set a really low bar for reaching out, you know, so that we can really adequately supervise and provide feedback.

[00:11:53] Dr. Cifu: So I'm jotting down notes as you talk, because I can sort of think of so many other purposes let's say, that this program lends itself to but you mentioned at the beginning that, you know, traditionally we've always put medical students in a doctor role, whether it be with a, you know, single physician kind of mentor or on a team. And what you've done with this is kind of supplement, right? Regular medical education. Could you see this either replacing traditional medical education or taking a bigger role where, "Look, you know, you're going to do six months of traditional medical education and six months where your patient panel is, you know, ten people and you're basically always in the hospital because those ten people are always being cared for."

[00:12:45] Dr. Tang: Yeah. That's an interesting question. I guess to your first question of whether or not patient-led education would ever take the place of physician-led education, I don't think so. I don't think that would be appropriate. You know, a lot of the training of medicine is about how do you take an interview? How do you listen for things that are emergencies? How do you form a broad differential diagnosis and form a management plan? And those aren't things that a patient can necessarily teach. That being said, I think it's a really important partnership in addition to that, to supplement, you know, how do you communicate with patients? How do you understand how hard it is to navigate the system? And, you know, how do you hear about how the side effects from medications are really affecting the patient's life? So there's a lot of things that I think are positive about it.

Now, I think what you're getting at is that actually some medical schools have something called a longitudinal integrated clerkship experience. And that is where during the clerkship year, instead of these traditional block rotations, where you have one subject matter at a time and kind of like through the year go through family medicine, internal medicine, surgery, et cetera, you have a panel of patients that are actually seen in this variety of clinics.

You also have preceptors in those different subject matters where you follow the patients through these different settings. I think that's an amazing model. I think that it can be a little overwhelming at the beginning of the year because they have to learn so many different things at the same time but over the course of the year, they develop this relationship with patients that they otherwise wouldn't have had, get to see what happens between visits, after visits and the evolution of care. And they really get, I think, a richer experience as well as a stronger kind of mentorship experience with a smaller panel of mentors.

[00:14:32] Dr. Cifu: Certainly does seem like both the density and the breadth of kind of pathology that students see in a traditional program might be hard in a fully patient-centered program...

[00:14:45] Dr. Tang: That's very true.

[00:14:46] Dr. Cifu: ...because a lot of the things we see and these rich learning experiences are pretty rare things that you're only going to see if you're on a team that's admitting a bunch of sick people.

One question about the program and then one totally out-there question. Emergency care? You know, if a patient who a student is following, you know, develops appendicitis in the middle of the night, do patients reach out to the students and say, "Hey, I'm going to the emergency room?" Or do they get like, you know, pinged by EPIC when the patient arrives in the hospital?

[00:15:21] Dr. Tang: Oh, that's it, that's an interesting question. So, you know, what I would say is the first year, you know, that we're piloting and we're trying to iron out all the kinks, you know, some students did give out their personal numbers, you know, and I think they did sometimes become this primary contact for patients. And, you know, we realized pretty quickly that it was not a good idea.

[00:15:42] Dr. Cifu: Yeah, yeah. Yeah.

[00:15:44] Dr. Tang: So we have a lot of rules in place as to, you know, what's appropriate contact and whatnot because I don't think that's appropriate for a first-year learner to have. That being said, you know, I think that, you know, people got creative, got Google numbers or other things and so some students, I won't say all students, some students really are quite tied in with their patients. They can't receive MyChart messages, unfortunately, we don't have that capability. We did have an EPIC-related reminder to some students about their patients being in the ER that was more tied to our comprehensive care program model but that wasn't possible to set up for all students.

[00:16:25] Dr. Cifu: It's interesting because you and I, as primary care generalists, right? I mean, I feel like any time one of our patients hiccups, we hear about it, right?

[00:16:34] Dr. Tang: Absolutely.

[00:16:35] Dr. Cifu: Usually through EPIC, but often in other ways. And we and our colleagues all have different styles about, you know, how our patients contact us but it's kind of where you grow into. And obviously, the complexity of a student who shouldn't really be answering the medical questions, it's hard to figure out where you draw the line.

My other question, I've had a kind of longstanding hobby interest in evaluating physicians and how terrible we are generally at evaluating physicians, right? I still say that I really have no idea how good I am from this, right? And most of the feedback I get is obviously incredibly flawed with, you know, Press Ganey evaluations or something, or it comes from people who have chosen to see me, have chosen to continue to see me, are in a weird power differential, you know, I ask the residents, you know, when I'm on service with them, like, "How was it?" But they're not going to give me an honest answer. And I've often thought that maybe the best way to do it is to like constantly embed our schedules with, you know, fake patients. But this, in a way, are... These are students who are not tied to the physicians whose visits they're witnessing. And obviously, it's a whole different training that they would need, but, you know, could you use these people to, I don't know, evaluate physicians or...?

[00:18:05] Dr. Tang: Oh, wow. That's an interesting question.

[00:18:08] Dr. Cifu: I'm just making you uncomfortable, I can tell.

[00:18:11] Dr. Tang: I think it's fascinating. I think that there probably still is quite a bit of a power differential at play there. It's a very interesting question. And I think that, you know, the question would be what are they evaluating on? You know, I think a first-year medical student can certainly provide some feedback on communication style. I think that perhaps their education, you know, I think it'd be hard for them to give any feedback on true medical care.

[00:18:43] Dr. Cifu: Maybe you need medical students from other institutions come to evaluate the faculty at different places.

Well Joyce, thank you so much for joining me. This has been a really interesting conversation and as a little bit of a prelude, we're actually going to have in a couple of weeks, two of your students with one of the patients they're following, which I'm really looking forward to sort of hearing from both the students and the patient about their experience in this.

So thanks so much for joining us for this episode of The Clinical Excellence Podcast. We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage or on Twitter.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.