May 3--CHAPEL HILL -- Changes in health care and a growing need for family doctors have prompted UNC-Chapel Hill and Duke to consider a dramatic shift in the way their medical students get clinical experience.
At UNC, the medical school may scrap the widely used "rotations" model, in which students spend a month or two in each of several specialties such as surgery and psychiatry.
In its place, they're eyeing a "longitudinal" model where students follow patients from the start of their treatment to the end. A few dozen universities, including some in other countries, have long employed this model, but it has gathered steam of late as medical schools place greater emphasis on teaching the total patient experience.
Officials at UNC, Duke and elsewhere are now questioning the rotation model, which allows students to hone skills through repetition but offers just a limited snapshot of the larger health care picture.
"If you're on a cardiology rotation, you see patient after patient after patient with chest pain," said Warren Newton, executive associate dean for education with UNC's medical school. "What you don't see is what happens to that patient later."
Duke's medical school will begin a small version of the longitudinal model this fall but has no immediate plans to replace traditional rotations.
Shift would be slow
At UNC, Newton is analyzing the two models and doesn't expect change to come quickly. But he likes what he sees from universities using the longitudinal model. And he is encouraged by the early results of a pilot program his med school is running now with just a handful of students studying that way at Mission Hospital in Asheville. Students there are performing as well as or better than their counterparts in the traditional program, he said.
There are logistical, financial and less definable obstacles to such a shift. Medical schools might have to wrangle additional practicing physicians willing to take on medical students, the new model might prove to be more expensive, and faculty members must be swayed to embrace the change. At UNC, the change would have to start slowly.
"You can't impose this," Newton said. "You have to pilot and spread it. This is a change of virtually everything we're doing."
Though dramatic, the shift -- which at UNC would affect third-year med students -- may be a necessary reaction to the nation's changing health care system. Some patient care has shifted away from hospitals to ambulatory care centers and other outpatient clinics, said M. Brownell Anderson, senior director for educational affairs with the Association of American Medical Colleges. Now, most hospital patients either have shorter stays -- shortening a student's learning window -- or have very specific illnesses that limit the learning process.
Students matched up with patients who routinely use outpatient clinics will get to know their cases far better, argues Anderson. Students at med schools employing the new model follow patients with an array of medical conditions, meeting them at the start of their treatment and following them to the end.
"It's more true to the kind of experience that a physician has," she said. "I've been going to the same doctor for many years, and she knows a lot about me."
Duke's medical school has long focused on producing critical care specialists and researchers. But with the need for primary care doctors on the rise, Duke is creating a new program -- using the longitudinal model -- for med students who want to go into that field, said Ed Buckley, vice dean for medical education with Duke's medical school.
Duke expects to start with four to eight students in the program this fall, a fraction of the 100 students in each med school class. The med school hopes to produce family doctors who better understand the entire health care process and can thus be forceful advocates for patients; they will even observe entanglements patients have with insurance companies, Buckley said.
Wherever they go
Under the new model batting around in Newton's head, third-year med students at UNC, who currently spend four to eight weeks on each of about eight specialty rotations, would instead follow patients with specific health problems as they navigate the treatment process. If the patient winds up in surgery, the student follows. If the patient is discharged and sent to physical therapy, the student follows.
That sounds pretty good to Harneet Gujral, a third-year UNC med student who likes the rotations model but knows its limitations. She had an interesting case recently, a patient with seizures and a congenital heart problem. But she only met him in the middle of his care, and was on to another patient before the end.
"I never got a full feel for the complexities of it because I got into it halfway through," she said. "I have patients with interesting cases who I have to say goodbye to. That's a big downside."
But the intensive instruction gleaned from rotations has benefits, as well. She honed her child-delivery skills quickly during her six-week obstetrics and gynecology rotation.
"The first time you see a delivery, you don't know what's going on," said Gujral, who is from Cary. "But it's easy to get good when you do several back to back. The repetition helps."
eric.ferreri@newsobserver.com or 919-932-2008
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