ON A HOT EVENING IN MAY 2001, A YOUNG GIRL ARRIVED AT THE Zuni Indian Health Service Hospital in Zuni, N.M., in obvious trouble. Her body was hot to the touch, her heart was racing, and her face was bright red. The 7-year-old was crying inconsolably. Most troubling of all, she was hallucinating, screaming in terror because of the snakes and bugs she saw emerging from peoples eyes and mouths.
For Eamonn Vitt02, it was a chance to play detective. Then a third-year P&S student in the middle of a five-week rotation in primary care, he was a three-hour drive from the nearest pediatric ICU in Albuquerque and even farther removed from Washington Heights in Manhattan. When Zuni patients needed to be transferred to larger facilities, clinic workers would call the pilots, and 20 minutes later a plane would land on a nearby airstrip. But when an emergency case came in through the door of the clinic, he was part of the first line of defense, and it was up to him and the rest of the clinics staff to figure out what kind of treatment was necessary.
It was clear to both Eamonn Vitt and the attending physician on duty in the clinic that her body was struggling against some sort of toxic substance. The only question: What had she taken? She was a pretty sick kid, he recalls.
A search through the girls medical records was all that was required to make a diagnosis. A family member had been advised to take Benadryl, and the young girl was showing all the classic symptoms of an overdose of the antihistamine. Those pills looked like candy, and it turns out that shed eaten about 30 of them, Dr. Vitt recalls. After stabilizing the girl, clinic workers placed her on a plane for the quick trip to the pediatric ICU in Albuquerque.
This was definitely real clinical medicine, says Dr. Vitt. His stint at the Zuni clinic came at the tail end of his third year at P&S, a year that is designed to be a practical application of the concepts and techniques taught during the first two years. At Columbia, that means a series of 10 rotations through different sites, where the students can work alongside practicing physicians in all of the fundamental fields of medicine and important specialties.
All rotations are important but some, such as surgery, are by nature more observational than participatory. But the primary care rotation is often a period when students are much more than just observers. They become critical members of a small, clinical practice, gaining valuable experience and providing needed care. Working at the Zuni clinic was a very hands-on experience, much more than any of my other rotations, says Dr. Vitt. The primary care rotation was definitely the highlight of my time in medical school.
The primary care rotation is the newest element of a busy third-year curriculum. Historically, the year was divided into eight rotations, each lasting up to six weeks. Basic medicine occupied two of the slots, with the remainder assigned to pediatrics, surgery, psychiatry, obstetrics/gynecology, neurology, and a variety of key subspecialties.
But Dr. Rebecca Kurth, associate professor of clinical medicine at P&S and one of the directors of the primary care rotation program, says the previous curriculum was heavy on hospital studies, and in 1994 she was part of the team that developed a new rotation in primary care. Dr. Matilde Irigoyen, professor of clinical pediatrics and chief of the general pediatrics division, co-directs the clerkship. While most clerkships are department-based, the primary care rotations leadership represents three generalist fields: general medicine, general pediatrics, and family medicine.
Before the primary care rotation, the majority of teaching in the third year took place in hospitals, and the education was focused more on the care of the critically ill and the critically injured, says Dr. Kurth. The focus was not on the bread-and-butter common problems that happen in a clinical environment.
Addressing that gap was one of the main goals in creating the primary care clerkship. The biggest shift was moving the educational experience out of the hospital, where treating inpatients is generally considered the main task, and into the outpatient clinic, where diagnosis is one of the most important steps. Today, every P&S student is assigned to a rotation at one of 22 clinical settings around the country. Primary care clerkships are offered in locations urban (Harlem Hospital and St. Lukes-Roosevelt, for example), suburban (Stamford Hospital in Connecticut), and rural (Bassett Healthcare in Cooperstown, N.Y., and Indian Health Service locations in New Mexico and Arizona). Other locations are St. Josephs Medical Center in Stamford, Conn.; St. Vincents Medical Center in Bridgeport, Conn.; Monmouth Medical Center in Long Branch, N.J.; NH/Dartmouth Family Practice in Concord, N.H.; and New York-Presbyterian Hospital.
This addition of locations outside the hospital mirrored a basic trend in the practice of medicine that was becoming more and more obvious in the mid-1990s. Improved medical technology means a growing number of medical techniques are performed on an outpatient basis. At the same time, the advent of managed care placed an economic pressure to move more procedures from the hospital to the clinic. The result is that most people receive the bulk of their health care in a clinic situation, once a place for basic checkups and inoculations. The needs of medicine have changed, says Dr. Kurth. We needed to bring students to where medicine really happens.
The P&S faculty was initially reluctant to adopt the new program. Dr. Ronald Drusin, associate dean for education who was then the associate dean for curricular affairs, says faculty were concerned about adding to an already packed schedule. The existing sessions already took up the entire year, which didnt allow any room for a new rotation. One proposal was to eliminate one rotation and substitute primary care, but that plan had no supporters and was quickly rejected. The school instead trimmed each rotation to five weeks and added a session despite faculty worries that shortening the rotations might limit learning in individual disciplines.
A bigger barrier was the culture of Columbia. As one of the nations most elite medical institutions, the school had traditionally put greater weight on studying the advanced specialtiesat the expense of learning the basics, some faculty argued.
Faculty were incredibly skeptical about this program, recalls Dr. Kurth. The general feeling was that working in a hospital setting would give the third years exposure to more advanced medicine, while working in a clinic would mean five weeks of taking temperatures and measuring blood pressure, valuable skills but not a good use the students time. The faculty wondered where the meat was in the primary care rotation. They didnt want the students to be wasting their time treating coughs and colds.
This reticence reflects the makeup of the faculty, which is heavy with skilled specialists. Even a residency program in family medicine did not exist at Columbia-Presbyterian until 1996.
Dr. Vincent Silenzio, assistant professor of clinical sociomedical sciences and former director of predoctoral education in the Center for Family Medicine at P&S, worked with Dr. Irigoyen and Dr. Kurth to administer the family medicine elements of the primary care clerkship. He says that teaching the basics of medicine is not lacking at P&S, but it is not always the focus of a students training. The primary care clerkship was designed to change that. By immersing students in a clinical setting, Dr. Silenzio says they see that a patient is not a collection of organs, each treated by a different specialist. Instead, they are single individuals, each with a body that must be treated as a whole. Too many doctors end up with expertise in, for example, just the left ear lobe, and they cant even look at problems in the kidney.
Despite the initial skepticism, the P&S faculty has come to see the primary care clerkship as a valuable experience. Students in the clinic spend much of their time interacting with patients, helping with diagnoses, and performing basic procedures. This is the meat in the program. Many of the naysayers were very quick to recognize that the primary care clerkship is a very valuable experience, says Dr. Drusin.
The students have been supportive of the program. One of our most common responses from students is that the clerkship made them feel like a real doctor, says Dr. Kurth. As a result of the program, many students now choose a career in general medicine.
In part, that was one of the goals of the program, says Dr. Drusin. In the early 1990s, along with the recognition that medicine was shifting to the clinical setting came a recognition of a shortage of skilled primary care doctors. The clerkship created an environment where primary care doctors could be seen as role models, he says, instead of seeing specialists as the top of the faculty pecking order.
Because the program was not put into place until 1994, the first students to benefit from primary care initiatives are still at the beginning stages of their careers. It is too soon to know how many will pursue a career in primary care. However, anecdotal evidence makes it clear that the number has increased significantly since the early 1990s.
Dr. Silenzio likes to compare doctors to musicians in an orchestra. A specialist may be an outstanding violinist but cant conduct the entire company. A physician with a solid foundation in general medicine may later go on to a unique subspecialty but can also provide basic primary care. Were trying to turn out both leading virtuosos and conductors at Columbia, he says.
Eamonn Vitt plans to become a conductor. My idea of what it means to be a doctor has always meant to be a generalist, says Dr. Vitt, a first-year resident in family medicine at Columbia-Presbyterian. Working at the Indian Health Service solidified my interest in going into family medicine.