BY MICHELE MCCARTHY AND LORRAINE THOMPSON
BY THE TIME MEMBERS OF THE CLASS OF 2011 WALK ACROSS THE commencement stage, P&S graduates should be as well versed in patient behavior, health policy, and professionalism as they are in physical diagnosis, pathophysiology, and human development. A $1.35 million NIH grant awarded to Rita Charon, M.D., Ph.D., will inject more social and behavioral sciences into the curriculum by training the teachers of a course that runs the full four years.
The five-year grant, “Enhancing Social and Behavioral Sciences in Medical School,” was awarded to P&S with Dr. Charon, professor of clinical medicine and director of the Program in Narrative Medicine, as principal investigator. The grant was awarded in March from the National Institutes of Health’s Office of Behavioral and Social Sciences Research, an office that promotes behavioral and social sciences research among all NIH institutes and centers.
The NIH put out a call for proposals partly in response to a 2004 Institute of Medicine report that called for programs that equip physicians with the knowledge and skills from the behavioral and social sciences that they need to recognize, understand, and effectively respond to patients as individuals, “not just to their symptoms.” The report noted that half of all preventable deaths in the United States are linked to behavioral and social factors, including smoking, sedentary lifestyle, poor dietary habits, and alcohol consumption. The behavioral and social science topics recommended by the IOM report as required learning for medical students were categorized into six domains of knowledge: mind-body interaction in health and disease; patient behavior; physician role and behavior; physician-patient interaction; social and cultural issues in health care; and health policy and economics. The report concluded: “No physician’s education would be complete without an understanding of the role played by behavioral and social factors in human health and disease, knowledge of the ways in which these factors can be modified, and an appreciation of how personal life experiences influence physician-patient relationships.”
Jaime Rubin, Ph.D., then acting associate dean for research administration, remembers her reaction when she read the NIH’s request for applications: “It just screamed Rita. It described her to a T. What particularly struck me was an emphasis on teaching physician-patient interaction and communication. Dr. Charon has tremendous experience in this area.”
For Dr. Charon and several other P&S faculty who are highly regarded for their informal and formal efforts to inject more humanism into the education of medical students, the new grant is a natural extension of their enthusiastic support of blurring the line between humanities and science. Dr. Charon has been creating curricula in physician-patient relationships, medical interviewing, cultural competence and reflection, and physician well-being for 25 years. Her pioneering work in the field of literature and medicine (her Ph.D. is in literature) led to the establishment of the Program in Narrative Medicine in the Department of Medicine. The program rigorously trains medical students and physicians in narrative skills such as the close reading of literary and clinical texts, writing about patients in common, everyday language, and writing reflective autobiography as a means of self-revelation. By building skills in narrative competence, physicians learn to be attentive to what their patients tell them not only in words, but also in silences, gestures, and physical findings. “They develop the ability to reconcile the multiple and often contradictory versions of a clinical story, to interpret their emotional responses to the patient, to fully imagine the individual patient’s predicament, and to assume the patient’s and family’s point of view as the events of illness unfold,” says Dr. Charon.
“When you look beyond the molecules and the flesh, everything that surrounds the diseased individual body that we doctors have to know about is the scope of this grant,” Dr. Charon says. “The grant is a bigger frame, but narrative medicine fits integrally into several of these domains.”
Since 1991, the Clinical Practice course “CP” has helped medical students learn how to be doctors from the first day of medical school. CP is a required, four-year course that brings together education on the physician-patient relationship, how health care is structured, access to health care, issues related to specific problems within medical communities, and cultural competency learning to appreciate and respect different cultures and customs. Ronald Drusin, M.D., interim senior associate dean for education, says CP “is really a wonderful opportunity for students to see where they’re going in medicine and how basic science remains the foundation for clinical decisions but how these decisions play out in patients’ lives.”
Delphine Taylor, M.D., directs CP I for first-year students and CP II for second-year students. In the first year, students
meet once or twice a week for lectures to the entire class and convene in groups of 15 students for weekly small groups. Each group meets with a preceptor for an hour or two. The preceptors are internists, pediatricians, psychiatrists, and family medicine physicians.
|In lectures, small group meetings, and clerkships, students come to recognize that the key to diagnosing and treating many complex medical problems is to ask good questions and to listen and learn from patients.
In addition to the lecture and small groups, students are assigned to a weekly, half-day clinical clerkship. Some are assigned to physicians in their offices and on hospital rounds, others to physical therapists, social workers, or homeless shelters.
“In lectures, small group meetings, and clerkships, students come to recognize that the key to diagnosing and treating many complex medical problems is to ask good questions and to listen and learn from patients,” says Dr. Taylor. “Clinical Practice aims to help students become effective clinicians who know how to counsel and heal patients in the context of their lives.”
It is in the CP curriculum that the new grant will take root. “I want to put more muscle into the CP curriculum,” says Dr. Charon. Much of Columbia’s grant will be spent on faculty development providing CP course teachers a two-hour weekly, graduate-level, intellectually intensive seminar from September to May. Ten CP I teachers will participate in the first year, and another 10 will participate in the second year of weekly seminars.
“Most of the material to be explored in the seminars already exists in some form in the CP curriculum,” says Dr. Taylor. “The boost to the curriculum will come to the students via the preceptors. The small group leaders will be better equipped with the knowledge and skills to encourage students to explore how this material relates to their current clinical experiences and to their careers.”
Michael Devlin, M.D., clinical co-director of the Eating Disorders Research Unit and course director for Clinical Practice III, co-wrote the grant application and credits Dr. Charon for using much of the grant money for faculty development. “Dr. Charon has thought a lot about how much the faculty could benefit, and our students could benefit, from developing ourselves as teachers and taking advantage of the resources that exist throughout the rest of the university.”
For third-year students, Dr. Devlin uses medical conflict resolution as one example of a topic covered in the Clinical Practice III pediatric clerkship, a topic that could be enhanced by bringing in people from Columbia’s law school to share
expertise with the CP faculty and, therefore, inform the teaching of medical students. “It’s our hope that by drawing on the resources within and outside of the university, we can take the faculty to a new level and teach our students in a much richer, more sophisticated way,” Dr. Devlin adds.
|There was lots of brainstorming about who might make good domain directors, what we were interested in doing in these six domains, what we were already equipped to do well, and what we had never done before but wanted a chance to try
The faculty seminars will be structured loosely around the six domains of knowledge. Seminars will consist of meetings, presentations, and classes with experts on aspects relative to a particular domain. Because Dr. Charon brings her background in narrative medicine to the project, the 20 clinician-educators will write about their practice and read aloud from their practice journals.
“March, for example, is going to focus on mind-body,” Dr. Charon explains. “For four weeks, we’ll be reading about and discussing elements of mind-body interaction.” Richard Sloan, Ph.D., will direct the unit on mind-body interaction in health and disease. Dr. Sloan, professor of behavioral medicine, is an expert on how risk factors contribute to the risk of heart disease. “Richard Sloan and his crew will help us learn what we want to teach our students,” says Dr. Charon.
The other domains will be directed by Dr. Devlin, associate professor of clinical psychiatry, whose medical interviewing expertise will help him lead the physician-patient interaction unit; Lynne Clemow, Ph.D., assistant professor of clinical medicine, who will lead the patient behavior domain; Dodi Meyer, M.D., assistant clinical professor of pediatrics, director of community pediatrics, and a leader in P&S cultural competency programs, who will lead social and cultural issues in health care; and Olveen Carrasquillo, M.D. assistant professor of medicine and director of the Columbia Center for the Health of Urban Minorities, who will lead the health policy and economics domain. Dr. Charon will direct the physician role and behavior unit.
“February is devoted to patient behavior,” says Dr. Charon. “Lynne Clemow and the behaviorists are going to come and teach us how to help people stop smoking, how to intervene in substance abuse or alcoholism or eating disorders. They’re going to make us better clinicians, so not only will my students benefit but my smoking patients will benefit as well.”
At the end of the first year, the 10 CP I preceptors who participated in the seminars will follow their students into CP II, as they normally do. Dr. Charon and her colleagues will then provide faculty seminars for the second group of preceptors who teach CP I.
“Over the five years of the grant, we’ll draw on the same pool of newly trained preceptors to staff CP III, which also breaks down into 10 groups of 15. There are 10 clerkships over the year and students rotate through them in a given order,” Dr. Devlin says. “Ideally each of these 10 groups will have its own preceptor and we’ll be drawing on the same pool of trained faculty.”
Mark Graham, Ph.D., director of educational research at the Center for Educational Research and Evaluation, also participated in the grant writing process. “What this grant has allowed Rita and her colleagues to do, while they’re still deeply involved in the CP curriculum, is to create a separate intellectual space to explore all these ideas more fully,” says Dr. Graham. “This is Columbia, we have a tremendous intellectual environment, and what Rita is trying to do is to bring all those players to the table, to create a complementary intellectual space and teach medical students to be more mindful; that’s what they learn in Clinical Practice. Now Rita has created a space for all of us to be more mindful about what we want to teach.”
Drawing upon what she describes as “Columbia’s great brain power,” Dr. Charon gathered faculty and students from all over P&S plus public health, nursing, physical therapy, and the Morningside campus to plan and design the grant project.
“There was lots of brainstorming about who might make good domain directors, what we were interested in doing in these six domains, what we were already equipped to do well, and what we had never done before but wanted a chance to try,” Dr. Charon recalls. “It was thrilling.”
“We are being asked to show that, at the end of the grant period, four-year undergraduate medical students graduating from P&S would know more about these six domains of knowledge,” Dr. Charon explains.
“Rita was interested in how we would evaluate what we wanted our students to know, to understand, to do relative to the domains the grant addresses,” says Dr. Graham. “We can’t evaluate anything yet because we haven’t set up the curriculum, but we’re taking a very novel approach compared to the other schools. What we did was to look at ideal outcomes, to look more ‘blue sky’ and ask what would we want our students to do, how would we want them to think through things, to understand situations, to take a perspective, to help someone stop smoking, and then not just deciding that ourselves, but having the individual players decide, bringing them together in an intellectual way and allowing lots of discussion. Rita is very good at doing that.”
“We will equip these 20 clinician-educators with intensive knowledge and skills in these six domains with the expectation,” says Dr. Charon “that it will make them better teachers not just for a year’s worth of medical students, but for an entire generation.”