Two weeks into their first year of medical school, six students confronted the case of a 60-year-old patient with advanced liver cancer at Calvary Hospital in the Bronx. After receiving chemotherapy, the patient earlier in the year had come to Calvary, a 200-bed hospital that cares for patients with late-stage cancer. Prepared for the worst, the patient surprisingly began to feel better and doctors sent him home.
However, a month later, the cancer recurred and he returned to the hospital. The second time around, the patient's parents are having a more difficult time facing the possibility their son is going to die. The parents are hoping for another remission, even though the patient's liver essentially has stopped working.
Dr. James Cimino, director of the Palliative Care Institute at Calvary Hospital, discussed the case with the students as an example of the delicate life and death issues Calvary doctors deal with daily. The talk was part of the students' education and addressed, among other things, how to interview new patients about their medical history and care preferences, including advanced directives. Dr. Cimino stressed the importance of asking recently admitted patients how aggressive they want their medical treatment to be so doctors can follow patient desires and prepare the patient and family for possible outcomes.
The training is part of the "selectives" or patient interaction component of Clinical Practice I, a required course for all first-year medical students. In the selective, each student meets with patients in a variety of settings, including Calvary, NewYork-Presbyterian Hospital and its affiliates, a young men's health clinic, a mobile healthcare van, and doctors' offices throughout New York City.
"In the fall semester, students learn how to translate scientific knowledge into clinical practice, what it means to be a doctor, and how to act appropriately," says Dr. Ora Pearlstein, course director and assistant clinical professor of medicine at P&S.
The course consists of lectures, patient sessions, and small group discussion sections of 15 students each week. Students meet with a cliniciansuch as a doctor, a social worker, or a physical or occupational therapistand patients at the healthcare site once a week for three to four hours. The meetings reinforce the lecture topics, such as medical interviewing, clinical epidemiology, health systems, ethics and values, and professional development, says Dr. Bruce Armstrong, selectives coordinator and associate clinical professor of population and family health in the Mailman School of Public Health. The students are supervised and not expected to perform any procedures for which they have not been trained.
"In the selectives, students learn how to interact and empathize with patients," Dr. Armstrong says. "Students don't learn how to do surgery or diagnose patients but learn the more fundamental principles of becoming a good physician."
The patient interaction part of the course became a requirement about six years ago. At the time, 70 percent of the students were active in an optional version of the program, which had been established in the 1980s.
As part of the course, students also write observations in journals each week after their patient sessions. Students sometimes are asked to read a passage from their journals in a small group session to discuss their experiences and integrate what they have learned in lectures and selectives. One student in the second week small group seminar asked whether questions about sexual activity and substance use are appropriate when taking the medical history of a 12-year-old girl at a clinicand if so, how they should be phrased.
For many students, the first patient contact is unforgettable. Perry Wilson, one of the six first-year students who went to Calvary, said speaking with a patient helped build his confidence and said, "I see how we can help patients by listening."
Jennifer Platt, a second-year medical student, completed a selective at Calvary last year. At first she was afraid the hospital would be a very sad place. Although she found some difficult days there, she says she was able to deal with death and that the hospital was a peaceful, soothing, and at times even a happy place because every effort was made to make the patient as comfortable and content as possible. Patients have cooks who prepare custom breakfasts every day, daily arts and crafts sessions, and a weekly happy hour cocktail cart with the best liquors.
"I learned that sometimes death is actually a relieving outcomefor both patient and familyof a long, drawn-out, and often painful battle with cancer," Ms. Platt says. But she also saw the dignity and strength in patients. "I learned there is still a person in there, under the tubes and IVsthat they can hear you even if they don't acknowledge you," she says. "You have to keep treating that person like a person, not just the body they may seem to be."