Learning for the long run

Kathleen White, M.D., likes to tell the story of the clinic patient who worried that her doctor was not there to care for her. Although surrounded by people in white coats with stethoscopes dangling from their necks, none of them was the person who knew and understood her medical history and with whom she had established a bond. They were doctors, but they were not her doctor. Her doctor was a medical student, working under the supervision of attending physicians. And the patient had been receiving her primary care at the Wednesday Evening Clinic.

Since the mid-1970s, the clinic has provided care to the New Haven community while giving students a chance to practice “longitudinal,” or long-term, medicine and learn how to connect with their patients. “This is the only place in med school,” said Fran Balamuth, the clinic’s student director, “where you get to see the same patient again and again.”

This is no small thing. Typically medical students spend no more than four weeks on each of their clinical clerkships. That time is often spent watching residents work, with an occasional chance to practice hands-on medical care under supervision. Some schools offer longitudinal preceptorships in the first two years of medical school, and some student-run clinics provide opportunities to assist in emergency care or serve as patient advocates. The University of Connecticut places first-year medical students with practicing clinicians, a match that continues through the third year of medical school, White said. But in general, at Yale and around the country, medical students have few opportunities to follow patients over time.

At the Wednesday Evening Clinic, the students are the first to see patients, the first to take histories and the first to conduct physical examinations. “The whole idea of longitudinal care struck me as being an awfully important one,” said John E. Whitcomb, M.D. ’77, one of the clinic’s earliest student participants, who now practices emergency medicine in Milwaukee. “I wanted to have a relationship with people.”

Added Lynn E. Sullivan, M.D. ’96, HS ’00, who spent 18 months in the clinic when she took time off from medical school to have her second child, “It isn’t the fleeting kind of experience you have on your clerkships. My patients would ask for me by name and only want to see me.” Sullivan, now an assistant clinical professor of medicine, is also one of the clinic’s attendings.

A year ago the clinic’s student practitioners honored the man they credit not only with founding the clinic a quarter-century ago, but with keeping it going and making it a warm and welcoming place to learn medicine. They held the first lecture in recognition of G. Morris Dillard, Ph.D., M.D., who served as the clinic’s director until five years ago. Howard K. Koh, M.D. ’77, M.P.H., now Commissioner of Public Health for the Commonwealth of Massachusetts, was the first speaker at the Morris Dillard Honorary Lecture, in January 2000. “On rare occasions, one has the incredible fortune to gain a mentor who changes your life,” Koh said of Dillard. “Dr. Dillard believed in us and in our full potential. He encouraged us to become doctors in our own way. When he adopted you as a student, he would stand by you forever.”

Dillard has counseled students, nurtured them and bucked up their flagging spirits. Each Thanksgiving he cooks one of his legendary gourmet dinners for the clinic. “He has made it a very warm, friendly and cohesive group of people,” said White, who succeeded Dillard as the clinic’s medical director five years ago. “He is the heart and soul of the clinic,” said Wendy Garrett, who is in her seventh year of the M.D./Ph.D. Program and until recently served as the clinic’s student director.

The clinic started in the mid-1970s, when students asked the medical school administration for a longitudinal primary-care experience. The administration declined, but invited students to organize their own program. “They gave the students the responsibility for forming the clinic, running the clinic and obtaining the appropriate support from the faculty,” recalled Dillard. Students found space in the Primary Care Center, which was closed evenings, and enlisted the support of physicians, nurses and support staff willing to volunteer their time. “At first it was very difficult to get patients,” said Dillard. “But we were the only clinic open at night in the hospital. We were the first clinic to have an on-call physician. We could be contacted 24 hours a day, seven days a week, every day of the year.”

Then, as now, patient population came largely through the Primary Care Center, the emergency department and self-referrals. Although it had the virtue of being open at night, the clinic also acquired a stigma it has since overcome. “The students endured the discrimination of being a student clinic, despite the presence of attendings,” said Dillard, who, along with clinic director White, leads a rotating cadre of faculty and community physicians who supervise the students.

A white-haired, bespectacled doctor who listens quietly as students present cases, Dillard seems, the students say, to know everything about everything. And he also appears to know things without being told. “I was having a bad night,” recalled Nir Modiano, a fifth-year student in the M.D./Ph.D. Program. It was half an hour past closing time and patients were still waiting to be seen. “Without knowing what was going on he came up to me, put both his hands on my shoulders and stood there for a few seconds. I don’t think he said a word. Then he turned around and walked away, and I felt better.”

The clinic’s caregivers get to know each other over dinner every Wednesday. They take turns providing the evening meal, often a stack of pizzas on the conference room table. As they eat, students and faculty discuss clinic business, such as a plan to obtain free samples for their patients from pharmaceutical companies. They may review an unusual case—one night it was a patient from the Sudan with a calcified worm under her skin. Often the group breaks up into two or three smaller sessions for case reviews with an attending. By 6 p.m. the students are ready for the two to four patients each of them will see.

“We do a thorough history,” said Modiano. “We do a physical exam and formulate our own thoughts, then present the patient to the attending.” The student returns to the examination room with the attending, who may obtain more history or conduct another physical exam. “The student may have already come up with a plan of treatment,” said White, “and the attending will verify specific exam findings and confirm the plan or alter or add to it.”

Some nights, when attendings are in short supply, the students wait their turn for a consult. Some students huddle with attendings in a corner or the doorway as others squeeze into the conference room to look for patient charts or grab a slice of pizza. Their cases run the gamut—a 76-year-old woman with a lung obstruction, a patient with diabetes, a woman suffering from osteoporosis, a patient with chest pain, a refugee from Sierra Leone with post-traumatic stress disorder.

One evening Sarah Nikiforow’s patient was Mary Jacob, a 35-year-old with cerebral palsy. With five years at the clinic (she’s in her eighth year of the M.D./Ph.D. Program), Nikiforow is the clinic veteran. Jacob, who has arthritis and occasional muscle spasms, has been her patient for years. “Don’t stop exercising,” Nikiforow told her, after a physical exam. “That’s what’s keeping you in such good shape.”

Ongoing relationships with patients are but one of the benefits of the clinic for students. Another is the chance to work with a network of physicians they will see repeatedly over the course of a year or longer. During their time at the clinic the students observe a variety of styles, including Dillard’s. “He steps back and does nothing at times and the students take over and make a decision,” said clinic director White. “He has made it a very academically challenging place.” Such longitudinal clinics, White said, provide an obvious benefit to medical students. “You watch them start as clumsy ducklings and then blossom into competent and caring clinicians.”

The clinic blends elements of the real world and an idealized vision of medicine. With their limited case loads and no need to make a living from clinical practice, students have the luxury of time denied many physicians. They are on call and often accompany their patients to other medical appointments or the hospital. “It’s a great opportunity for the patients,” said Shelly Harrigan, R.N., who’s worked at the clinic for three years. “The students do excellent follow-up.”

“Patients who have medical students helping to take care of them are some of the best-cared-for patients,” said Sullivan. “The students are just aching to see patients and start being doctors. This is a way in which they can do it in a very organized, safe and nurturing environment.”

Dorothy Mosley, a patient at the clinic since 1981, has never thought twice about being seen by medical students. “I had all good ones,” she said. “I knew if I had a problem I could call someone. They are helping me through my crisis right now. When my husband passed away in May, Dr. Dillard was right there for me. Wendy Garrett was right there for me.”

The students themselves, White said, have asked for some changes in the program. They want more constructive criticism from the attendings and more detailed instruction in giving a physical examination. “The nature of the clinic is that we attempt to give feedback at the time, as difficult as it is,” White said, adding that Herbert S. Chase Jr., M.D., deputy dean for education, is planning an evaluation of the clinic’s value as a teaching tool.

A year in the clinic replaces a month-long primary-care clerkship, making it very attractive to students in the M.D./Ph.D. Program, who have filled most of the 14 student staff positions for the past three years. The clinic lets them advance their clinical skills while they work on their research projects and it provides a welcome break from days in the lab. Students in the clinic are trying to broaden their outreach and recruit more students outside the M.D./Ph.D. Program.

By 9 p.m. the students are seeing their last patients of the evening. Long after patients have left, the students will stay on, writing up their notes from the evening’s cases. Few leave before 10 p.m. and some stay until midnight, filling out charts. “There is no doubt in my mind that the care our patients receive is surpassed by no other clinic,” said Dillard. “The original clinic was designed by students to meet one time a week throughout the entire year, to be responsible for patients every day throughout the year. In return, the students receive an educational experience equal to the clinical responsibility.”