Whitney Palmer

Change Agents: Training Doctors as Change Agents for Community and Primary Care

Published in the Summer 2011 Duke Med Alumni News

By Whitney L.J. Howell

When Tracey Spencer enrolled in Duke University School of Medicine’s Class of 2013, supporting a patient’s leg in the delivery room was not the first clinical care image that popped to mind. But earlier this year, that is where she found herself, and she says it is one of the greatest parts of her medical training so far.

“I held my patient’s leg for an hour while she pushed. I never really thought about deliveries taking that long, but 30 minutes into it, her leg started to feel really heavy,” says Spencer, MSIII. “It was my first time seeing a baby delivered, and when I needed to take a break to avoid passing out, they waited on me. The patient was so comfortable with me and really considered me to be a big part of her care team.”

Spencer’s experience is unique among her peers because she is part of a new program for second-year Duke medical students called the Primary Care Leadership Track (PCLT). This academic path is an effort to answer the Association of American Medical Colleges’ recent call for medical schools to  produce more primary care physicians.

As with many aspects of medicine, however, Duke is putting its own twist on things. Rather than  follow the traditional second-year curriculum focusing on inpatient training in the hospital, the PCLT places students mostly in outpatient settings, such as primary care, community, and obstetrics-gynecology clinics. The change gives them first-hand experience in the predominant primary
care settings.

Forming the Program

The past five years have been a time of growing pains for Duke’s primary care and family medicine programs. Since shuttering the family medicine residency in 2006, the school revamped the program, and administrators redoubled their commitment to primary care training. The same enthusiasm arose when faculty began discussing the PCLT, says Edward Buckley, MD, vice dean for medical education.

“Duke’s fundamental educational mission is different from other schools,” he says. “While we do train physicians focused solely on patient care, we also have a commitment to train clinical leaders and scientists who can be change agents for health care at the community and primary care levels.”

In fact, says Barbara Sheline, MD, MPH, PCLT program co-director and assistant dean for primary care, getting buy-in from school administrators and lead faculty took less effort than program coordinators anticipated.

“After we presented our thoughts and plans for the program, the overriding consensus was that this is the way we should’ve been teaching primary care all along,” she says.

Finding five faculty preceptors for each PCLT student was the first step to successfully launching this part of the curriculum. Every student must have a preceptor from each core area— family medicine, internal medicine, psychiatry, pediatrics, and obstetrics-gynecology— so Duke provides faculty development to physicians who do not regularly teach.

Students spend nine months in outpatient clinic training, and they also have the unprecedented  opportunity to rotate through the emergency department. Inpatient training comes by spending nearly three months working in the hospital. Throughout the year, they meet with Sheline every Thursday for instruction and discussion.

Although the PCLT opened with three students enrolled, nearly 200 applicants applied for the six slots available next year, Sheline says. Interest was so great that within 48 hours of posting program information online, coordinators received 96 inquiries. Faculty select students based on a written essay and a separate interview in which program leaders look for applicants with demonstrated or potential leadership skills.

Accepted students receive a $10,000 scholarship to offset the cost associated with pursuing the often lower-paid primary care positions. If students decide to enter a different specialty, the scholarship reverts to a loan.

How It Works

While PCLT students begin the same curriculum as their classmates, taking basic science courses during their first year, they also discuss patient cases with other health care professions students. They branch away further as second year students by learning in different environments. Instead of spending the majority of their time with hospital inpatients, these second-year students rotate through outpatient clinics.

Each week, they spend half-days shadowing their preceptors, taking patient histories, and learning to hone their diagnostic skills. Time spent in the clinics gives students the benefit of one-on-one time with faculty, says Bruce Peyser, MD, PCLT co-director from internal medicine.

“Second-year students naturally need more time and supervision than fourth years, and in many cases they’re starting from square one. They can’t find a lymph node or aren’t skilled enough to hear a heart murmur,” Peyser says. “But working alone with a doctor means they get more time to make sure they’re doing things correctly and we, as faculty, can take time to really show them things and make sure they understand or can ask questions.”

In addition to observing patients with their preceptors, PCLT students also get their first taste of being a “real doctor.” They are required to compile their own panel of patients—a group of individuals whom students follow through the health care system as they need and receive services. For instance, if a primary care provider refers a patient to a specialist, the student would accompany the patient to the appointment as a patient advocate and to provide an extra continuity of care layer.

Having an individual panel of patients gives PCLT students a first-hand glimpse into the life and  responsibilities of a practicing provider far earlier than any of their peers.

“I don’t think even fourth years or residents get the same continuity with their patients,” says  Christopher Danford, MSIII, who chose Duke over other medical schools specifically for the PCLT program. “All three of us have had a patient we’ve been close to die or get a new diagnosis of cancer. And on the other end, we’ve been able to deliver babies. That’s a very emotionally charged experience.”

The Centering Program through Lincoln Community Health Center offers PCLT students the opportunity to follow pregnant patients through their health care experience. Together with a nurse midwife, the students work with a group of women throughout their pregnancies, providing prenatal care and leading Program discussions. The students are present for the births— many delivering the babies—and they follow mother and baby to postnatal care.

“It’s wonderful for the women to get to know the students and have them at their births,” says Trish Payne, a certified nurse midwife who serves as a PCLT preceptor. “These women walk into the hospital to have their baby and instead of seeing a stranger, they see their medical student.”

The program is too new to provide longitudinal data on the benefits of having medical students involved in prenatal care, but Payne says she anticipates the Centering Program women will not only be more likely to listen to and follow the students’ advice, but they will also be at a lower risk for a C-section because they will be less frightened in the delivery room.

The Program ’s Next Steps

Real-world primary care training continues for PCLT students in the third and fourth years of medical  school. During the third year, according to program co-director Sheline, students must complete a research project in collaboration with the Duke Center for Community Research that focuses on a community or population health issue facing Durham residents, such as diabetes in the African- American population.

“This is the year where students will really see the health care system through the patient’s eyes,”   Sheline says. “They will work with groups already looking at health issues Durham cares about while receiving training in community and population clinical leadership.”

The PCLT fourth year will be similar to the traditional fourth-year curriculum. Students will choose a variety of electives designed to increase their primary care proficiency, including a sub-internship and a critical care elective. Additionally, PCLT students must complete a four-week long capstone course that will better prepare them to work in a patient-centered medical home.

Another View of Health Care

Even though they have only finished the program’s second year, the three PCLT students have already achieved one of Duke’s goals—they are far more aware of what it means to be a patient in today’s health care system.

“It’s been most interesting to see the transition of care as a patient goes from different practice to  practice. I’ve realized that many patients have trouble getting to and from appointments because of transportation issues, and I’ve seen them struggle to make their co-pays,” says Cassandra Kisby, MSIII. “I know our classmates don’t see that because they’re transferring from service to service rather than rotating with the patient.”

The effect so far—on student and patient—has been positive, says co-director Peyser. The need for strong leaders in primary care is especially great as the health care system faces a time of substantial transition. The continuity of having students in the clinic is also comforting to patients.

“Without fail,” Peyser says,” the patients who agreed to have Chris [Danford] as part of their care ask for him and want him in their appointments.”

June 13, 2011 - Posted by wjpalmer | Education, Healthcare | Association of American Medical Colleges primary care education, Barbara Sheline, Bruce Peyser, Cassandra Kisby, Christopher Danford, Duke Center for Community Research, Duke Medical School Primary Care Leader Track, Duke University School of Medicine, Edward Buckley, internal medicine, Lincoln Community Health Center, medical students delivering babies, medical students learning about patient barriers to care, medical students seeing patients, medical students treating patients, medical students working in clinics, obstetrics-gynecology, PCLT, pediatrics, pre-natal program for low-income women, primary care change agents, primary care education, primary care patient advocacy, primary care preceptors, psychiatry, scholarships for primary care training, second year medical students studying family medicine, second-year clinical training, second-year medical student community health projects, second-year primary care training, The Centering Program, Tracey Spencer, Trish Payne