Shouldn’t the beginning be at the beginning?: The role of the undifferentiated patient in novel patient-centered curricula.

I wrote this opinion piece during my fourth year of medical school.  I was going to submit it to a print journal, but it got lost in the mix of applying for residency, finishing up research projects, and transitioning to residency and a new city.  
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It outlines my argument for medical students in the ED at an early stage in their schooling and the value of the undifferentiated patient.

There has been a recent concerted effort by US medical schools to expose undergraduate students early in their training to patient interactions.  In fact, the novel Curriculum for the 21st Century (C-21), which has recently been debuted at the NYU School of Medicine, exposes students to patients on the very first day of school.  The curriculum also will place many students in an Emergency Medicine Selective as early as 18 months into medical school.  This will serve as the first full-time clinical rotation for many of our students.

To those accustomed to a more traditional approach to undergraduate medical education, the idea of 18-month-medical students populating the wards can be unsettling.  However, development of physical exam and history taking skills before entering the wards will now be accomplished by a concerted emphasis on early exposure to the patient.  

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It is common sense that primary school educators do not ask students to learn words until they have first learned the letters of the alphabet.  We do not read the end of paragraph, and then go back to its beginning to find out what had happened.  The undifferentiated patient exists within our emergency departments and ambulatory clinics.  So why is it that we ask our medical student clerks on the wards to piece together a patient’s past history before the student has even had a chance to be exposed to the realities of those events?

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The traditional manner of requiring clerks to manage patients with preset diagnoses before they have had the experience of managing an undifferentiated patient may need to be reconsidered.  For example, we ask students during their Internal Medicine clerkships to manage the heparin drip of a post-STEMI patient on the ward, but the student may never have seen a patient in the throes of substernal chest pain – which is the very event that led that patient into that hospital bed.  These students conduct patient histories and report back to their superiors the answers to questions such as, “What happened first?” and “What happened when you went to your primary care doctor with your concerns?” and “What happened in the emergency room before you were admitted?”  We are unfairly asking the student to string together a story based on events they have never witnessed.  It’s like asking someone who’s never seen a tree, to understand how paper is made.

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Early exposure to the undifferentiated patient is logical. 

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Emergency Medicine and Ambulatory Care settings need to be utilized early to realize the success of novel patient center curricula.  In fact, their unique shared characteristic of housing the undifferentiated patient may make a logical solution to the transition of students from their now oxymoronic preclinical years to their clinical clerkships.  At only 18 months, the 21^st century student will possess the preclinical knowledge of pathology and physiology that the 20^th century student possessed, but they will also possess quality physical exam and history taking skills that are superior to their predecessors.  We propose medical educators involved in novel patient centered curricula embrace the early placement of students at the bedside of the undifferentiated patient to allow students the development of skills to understand the beginnings of disease and pathology.

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After they are exposed to the beginning of patient’s pathologies, it is only logical that students will ask, “What’s next?”  They will then populate the wards and discover the answer to that question themselves.

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Watch more about the NYU SoM C-21 Curriculum narrated in part by Dr. Mary Ann Hopkins (one of my mentors):

- Teach, MD