Teaching Doctors To Care

By Nathan Thornburgh/Boston

Claire Brickell, 25, an aspiring neurologist in her third year at Harvard Medical School, already knows far more about health care than most of us. She can diagnose heart failure from a chest X ray. She can diagram the intricate circuits of the brain. And if she needed to, she could probably pull off a pretty decent tracheotomy. But when it comes to communicating with patients, Brickell has a problem: she's too healthy. Like most of her classmates, she has spent very little time as a patient. She has never had to weigh the advice of a trusted friend against conflicting orders given by a cold and distant doctor. She has never had to take daily injections for a disease she doesn't understand. She has rarely even gone through the most basic crucible of illness in the U.S., the interminable wait in a doctor's office.

Enter Santa Ocasio, 56, a Dominican immigrant who is fighting a protracted battle with Type 2 diabetes. In a pilot program that is the leading edge of a broad curriculum overhaul at Harvard Medical School, Brickell has been paired with Ocasio for nearly five months. She sees her as a patient every week at the Spanish Clinic of Boston's Brigham and Women's Hospital and tags along on visits to her specialists. In fact, the goal is for Brickell to be there every time Ocasio encounters the health-care system. It's not just a way to learn about treating diabetes; it's a crash course in the myriad frustrations of a patient caught in the maw of modern medicine--confusing prescriptions, language barriers and an endless parade of strangers in white coats.

Why would the U.S.'s top medical school ask its students to spend valuable time trailing a patient instead of a doctor? At Harvard and other medical schools across the country, educators are beginning to realize that empathy is as valuable to a doctor as any clinical skill. Whether it's acknowledging that a patient was inconvenienced by having to wait an hour before being seen or listening when someone explains why he didn't take his meds, doctors who try to understand their patients may be the best antidote for the widespread dissatisfaction with today's health-care system.

So Harvard has built closer partnerships between students and patients into the principal clinical experience, a small but important part of its most significant curriculum reform in two decades. The University of Pennsylvania Medical School began a similar program in 1997, and other schools are following suit. As long as medical students are still getting a healthy diet of clinical learning, educators say, there's little downside.

Still, centering clinical learning on patients is a fairly radical concept for a medical-education system that is notoriously resistant to change. Medical schools operate largely on principles established in 1910. For most of the intervening century, the third year of medical school has meant total immersion in a series of clerkships in the major fields--six weeks in cardiology, six weeks in intensive care and so on. Students met patients when they were admitted into that section of the hospital, and the relationships ended as soon as the patients were discharged or moved to another ward.

Dr. Erik Alexander, who directs the new program at Brigham and Women's, says the old model prevents students from seeing the larger picture. Every patient is a complex combination of sickness and health across multiple biological systems, and patients are regularly shuttled between various parts of the hospital in the course of their treatment. The best doctors in the future, he says, will make those connections across fields and treat the patient as a whole individual, not a series of symptoms.

Cambridge Hospital, a Harvard-affiliated branch of Cambridge Health Alliance, took the patient-partnering concept even further, including group lunches and, in some cases, home visits. Dr. Barbara Ogur, who co-directs the Cambridge pilot program, says that for too long, medical students in their third year suffered what she calls "ethical erosion," in which the pace and pressure of the hospital floor desensitized students to the physical suffering and minor indignities of being a patient.

For third-year student Rachel Bortnick, 27, a science buff from childhood, one of the lasting lessons is that patients sometimes don't want the help she is being trained to give. One cancer patient, whom she had followed from initial diagnosis through treatment, decided to quit chemotherapy so that he could leave the hospital, essentially to die.

"It's hard to watch a patient at death's door," says Bortnick. "You want to do something to prevent it. But this patient really wanted peace and quiet, to be somewhere he wouldn't be intruded in on by doctors every hour of the night." Bortnick eventually made peace with her patient's resignation, and after he died earlier this year, she attended his funeral.

It's clear that experiences like that are meaningful to the students, but health-care advocates say patient-centered rhetoric has been around for at least as long as HMOs. The fact is, even the most exquisitely ethical medical students will have to work in a health-care system that is driven by the pressure of the bottom line. Marcia Hams, program coordinator with the health-care advocacy group Community Catalyst, says Harvard has the right idea. For students from other Boston-area medical schools, her organization tries to impart a similar lesson with Walk in My Shoes, a program that asks students to simulate patient tasks like signing up for Medicaid or searching for an interpreter in a hospital. But Hams cautions that it will take more than curriculum reform to get patients the care they deserve. "If doctors only get a minute and a half with a patient," she says, "then whatever they learned in med school about patient needs isn't going to matter a lot."

For Dr. Guillermo Herrera, who has been running Brigham and Women's Spanish Clinic since he founded it in 1971, better patient-doctor communication is exactly what his growing Hispanic patient population needs. The close relationship between Ocasio and Brickell has helped Ocasio navigate her way to a more honest dialogue with doctors--and eventually to better health. Ocasio had resisted treating her diabetes for a dangerously long time, for example, and even after she started going to the clinic, she refused to take her medication. Only after spending a few weeks with Brickell did Ocasio open up enough to say that back in Santo Domingo, her friends had told her that insulin caused blindness and led people to have their limbs amputated. After Brickell heard that, she was able to convince Ocasio that those were symptoms of the disease, not the insulin. For the first time in her life, Ocasio has been taking her insulin regularly, and she's feeling much better.

Brickell says the experience taught her that learning to see the world from the patient's point of view isn't squishy science; it's a way to get the kind of results everyone wants from the medical system. "Doctors aren't supposed to feel sorry for their patients. They're supposed to fix them," says Brickell. "And I think this program will help us do that."