When I was a student at Tulane, there was a story (possibly apocryphal) that illustrates how medical education used to occur. The Endocrine Clinic (a training clinic for Internal Medicine residents) at Tulane used to take care of a lot of patients with overactive thyroids. They would place them on medication (Propylthiouracil, expensive, had to take three times a day) and monitor them roughly every 2 months from signs of worsening or problems with the medication. One Christmas break, the surgery residents broke into the clinic, pulled the charts of all of the patients on this medication, and called them to ask if they were interested in having an operation that would eliminate the need for this medication (but possibly lead to the need for thyroid replacement therapy). After the clinics reopened, many of these patients came back for their follow-up with a fresh scar from their thyroidectomy. The chairman of Medicine, a clinical giant named C. Thorpe Ray, went into the Dean’s office and proceeded to rant loudly about the surgeons. The chairman of Surgery, called in special for the occasion, let Dr. Ray rant. When asked for his response, he answered simply: “The boys need thyroids.”
This had been the training philosophy in medicine since the model for modern medical training was established following the Flexner Report. Learners were placed in large hospitals and practiced on folks who needed care. Folks in need went to the large hospitals to get care. Some folks might get care they didn’t need or want but… the boys needed thyroids.
Medical training, though, is changing.
A new report from the AAMC provides the results of a 2010 survey of member institutions to determine how attributes of the patient-centered medical home are being incorporated into the clinical education environment. While few studies have examined how medical homes have been integrated into teaching settings, “Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery,” offers examples of seven medical schools successfully delivering patient-centered care to their communities. The report also discusses the challenges and opportunities in the post-health care reform era for medical schools and teaching hospitals to develop new ways to train physicians and improve the health of the public.
And now Tulane offers community-based training at several Federally Qualified Community Health Centers across the city (from the AAMC report)
While training in an NCQA-recognized patient-centered medical home has profoundly affected the resident ambulatory experience, (there is currently a waiting list of residents who wish to train at Covenant House) their exposure to innovation extends outside the health center walls. The team has partnered with numerous local nonprofit civic and religious groups in efforts to “get our tentacles into the community,” and allow faculty, residents, and medical students to train community health workers through culturally sensitive care management programs. Faculty have noted the quick ability with which residents become “savvy” with the resources available to the community, and, as indicated by Dr. Price Haywood: “Residents play a key role in helping patients negotiate the community.”
A far cry from the boys needing thyroids.