Students begin core clerkships after three semesters
By Dawn Goodlove
Roger Sur had just come out of the exam room after taking his first patient history and was presenting the case to his physician-mentor in the OB-GYN clinic. As Divya Shah, MD, typed details into the electronic medical record, it was obvious Sur hadn’t collected a thorough narrative of the patient’s condition. So he returned to the exam room with Shah and watched her interview the patient.
“She showed me I have to dig deeper to clarify the information I’m getting from the patient,” says Sur, a second-year medical student in the University of Iowa Carver College of Medicine. “It’s one thing to hear about something in a lecture and then go practice on a standardized patient. But to practice in a real clinic is a whole other learning experience.”
Medical students quickly move beyond lectures and labs and into the live clinical environment on the college’s New Horizons curriculum. Within weeks of starting their first semester, students interview patients under the guidance of a physician-mentor and observe a variety of providers in action. These Early Clinical Experiences jump-start development of good interview and physical exam skills, which are critical for the core clerkships that start after just three semesters of preclinical instruction—a semester earlier than is the common practice at other medical schools.
“In lectures we hear about social determinants of health and health disparities, but when I see a patient, I have a face to put with the material I’m studying, which is a much more powerful statement for me,” says second-year medical student Lauren Boland. “It’s helpful to have that connection and carry it with me as I’m going through times of test after test.”
Done with year one
A year ago, Medicine Iowa started following Sur, Boland, Anna Mark, and Brad Egbers as they began their medical education at the UI. Their class is the first to experience, from day one, a revised curriculum that integrates the basic sciences with clinical applications throughout their training and provides more flexibility in students’ experiences.
Even technology gives them more options: Buy the textbook, or read it on a laptop for free through the AccessMedicine database of UI’s Hardin Library for the Health Sciences. Take the weekly quiz online anytime Friday through Monday, or multiple times if attempting to improve a score. Attend a lecture, or download the podcast recording and listen later, as Egbers has started doing.
“At the Naval Academy, attendance was mandatory, and I couldn’t break that habit initially in medical school,” he says. “But now I can watch lectures at one-and-a-half-times speed, so that saves 10 minutes, plus transit time to campus. If you objectively evaluate it, you realize it’s more efficient to watch lectures on the computer.”
Egbers earned a bachelor’s degree in electrical engineering at the Naval Academy and spent five years as an aviator before enrolling in medical school. That technical background helped him land a position last summer working in the lab of Michael Abramoff, MD, PhD, professor of ophthalmology and visual sciences, biomedical engineering, and electrical and computer engineering. Using his background and skills in software development, Egbers works with Abramoff’s team to harness the power of computing devices—specifically graphics processing units—for automated retinal image analysis. The goal of this research is to more effectively and efficiently screen patients for diabetic retinopathy, age-related macular degeneration, and glaucoma.
Sur and Mark spent part of their summer at Iowa community hospitals through the college’s Medical Education in Community Orientation (MECO) program. Sur was at Jones Regional Medical Center in Anamosa, and Mark—who married Alex Mark (’14 DPT) in June—was at the Winneshiek Medical Center in Decorah, where her father, Kevin Locke (’86 MD), is on staff.
“I had shadowed my dad in the past but I was able to keep up better after I had been in medical school for a year,” Mark says. “I was able to help with a delivery and also scrub in on a C-section. I learned how to do a punch biopsy and practice suturing. And I was able to practice my interviewing skills and work on presenting patients to the physicians as well.
“The experience made me remember why I wanted to go into medicine in the first place. Now I’m much more excited for the clinical years,” she says.
Boland divided her summer between two UI laboratories to help determine which lab she’ll choose for her PhD work in the dual-degree Medical Scientist Training Program (MSTP). She picked the lab of James Ankrum, PhD, assistant professor of biomedical engineering, in the new Pappajohn Biomedical Discovery Building. As a member of the Fraternal Order of Eagles Diabetes Research Center, Ankrum studies mesenchymal stem cells and their potential to restore function to damaged tissue, which could help patients with diabetes and diabetic complications.
“Sometimes research gets bogged down in characterizing the problem, but this lab is focused on creating solutions,” Boland says. “I’m excited by the questions being asked here.”
Like other second-year medical students, Boland starts her clinical rotations in January with the weeklong Transitions to Clerkship workshop.
“This fall semester is intense because we focus on transitioning to a clinical reasoning mindset,” Boland says. “We’re dealing with both basic science and how to apply it in the clinic.”
Second-year medical students spend the spring semester in core clinical clerkships. Boland, however, will do only 12 weeks of core clerkships, using the semester’s remaining weeks to study for and take Step 1 of the U.S. Medical Licensing Exam. Her MD classmates take Step 1 midway through the third year following their core clerkships. After the exam, Boland begins training for her PhD with three to four years of graduate coursework and research before returning to the MD curriculum for three semesters of clerkships and completion of her MD/PhD.
Beyond the books
Away from their studies, the students have responsibilities to spouses or significant others, children, and pets. Plus, they squeeze in extracurricular activities that undoubtedly enhance their medical education experiences, or at least provide a study break.
During one of the college’s Mini Medical School community outreach programs focusing on STEM—science, technology, engineering, and math—Sur volunteered with other medical students and providers to teach middle school students about medical technology such as automated external defibrillators and the EEG. He also mentors a first-year medical student from his home state of California, as well as an undergraduate chemistry major considering a career in medicine.
“I’ve been interested in taking on a mentee to share what I’ve learned and give any advice that I can. Looking back during my education, I wish I’d had that. I had some mentors along the way, but in the beginning it was me learning by trial and error,” he says.
Egbers and Boland have volunteered with community health clinics. When he was stationed at a Navy base in Jacksonville, Florida, Egbers was a Spanish translator at a free clinic. Here he has helped the UI Mobile Clinic, which provides free health screening, physical exams, health education, and other services to uninsured or medically underserved populations. Over the summer, he coordinated the clinic’s interaction with Proteus, an organization that offers health care to migrant workers who might not have access to care otherwise. Boland worked with the Iowa City Free Mental Health Clinic, shadowing more experienced medical students when they interviewed patients.
“It’s interesting to see someone in a senior position do the things I’m interested in doing,” Boland says.
Mark is co-president of the Iowa chapter of the American Medical Women’s Association. Among its services, the chapter provides a mentorship program that pairs female medical students with female physicians. The organization also chooses service projects that support women’s health in the Iowa City community.
Learning holistic health care
As students progress through the curriculum, they are learning about the connections between health and disease, people and their environment, and their health care providers.
“Your patient’s story isn’t just the symptoms they are describing,” Boland says. “There are a lot of other elements influencing their condition.”
She recalls one patient who came to the clinic during her first year.
“She’s struggling with diabetes, is obese, and has other issues. Through the course of our interview with her, she revealed she was homeless. Talking with my physician mentor afterward, I asked, ‘How do you work with people so you provide them with something they can take away?’
“My mentor said you have to do as much as you can in this moment and provide them some stability that might help later on. You can’t, in one session with somebody, fix every single problem and send them away totally healthy and perfect. Learning how to do what you can and making sure patients understand the support systems available is a big part of being a physician.”
New Horizons: Year 2
• Medicine and Society (final section): Health services organization and delivery, especially related to community dimensions of medical practice and patient safety
• Clinical and Professional Skills (final section): Students shadow third- and fourth-year medical students on their rotations; practice taking histories and performing physical exams in UI Hospitals and Clinics inpatient units, under the supervision of physician-mentors; and interact with standardized patient actors
• Mechanisms of Health and Disease (MOHD; final section): Psychiatry, rheumatology, dermatology, immunology, bacteriology, neurology, orthopedics, trauma
• MOHD Keystone: Final basic science course before clinical rotations; students learn approaches to common clinical problems and diseases while making connections to the relevant underlying science
• Core Clerkships: Students complete half of the following rotations: ambulatory care (community-based primary care, outpatient internal medicine, family medicine), internal medicine, neurology, OB-GYN, pediatrics, psychiatry, surgery
• Mock exam for Step 1 of U.S. Medical Licensing Exam; actual exam taken January-February 2017
Read the first installment in this series, “Many roads, one destination”