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Expanding the Horizons of Medical Students

Dr. Ben Robert, medical director of the Perley and Rideau Veterans’ Health Centre in Ottawa. Dr. Robert shares his insights into how medical curricula should reflect the shift in patient demographics.

I fondly remember medical school, but in retrospect I can see that my training was very narrow in scope: we were taught to have a single-minded focus on curing people, stopping disease in its tracks and saving lives.

As a medical student, I received no training in how to do house calls or palliative care and my training in primary care was minimal. All of my education was in a tertiary hospital setting. After I completed medical school, my rotating internship and additional one year of family medicine training again focused primarily on hospital-based approaches.

To be fair, when I was a student, house calls were considered to be part of Canadian medicine’s past, and palliative care and care of the elderly were fledgling ideas that were thought to be more appropriate for European approaches to health care.

Fortunately, medical education has improved much over the years. Educators are increasingly recognizing the value of primary care and the importance of building relationships with patients over the long term, not just providing care for an acute illness. The health consequences of frailty in older patients are also receiving more attention.

Over the course of my career, I have learned to appreciate the impact of disease, the isolation produced by disability, and the toll taken by the fear of loss of control. If I were to adjust medical school curricula on the basis of the lessons I’ve learned, a far different approach would be taken to training all future doctors.

I envisage medical students being introduced to frail patients from their early days in medical school. In Ontario, for instance, first-year students could regularly (perhaps once per month) participate in patient encounters through the Community Health Links program.

In this program, hospitals, family doctors,specialists, long-term care facilities and community organizations work together to care for patients with complex needs. The students could learn how to take a patient’s history during these encounters and could be given assignments to complete that relate to the problems that are discussed during the visits.

These encounters would continue in the second year, with more emphasis on learning about the underlying disease processes and about how to treat them. Second-year students would also get to experience house calls with Health Links professionals. Imagine the impact that this type of exposure during medical school would have on all aspects of care: students would learn the importance of creating goals of care, they would see firsthand the impact of disability and disease, they would learn how to approach caring for the frail elderly and they would understand the limitations of therapies.

During the first two years of medical school, I would also introduce more humanities training. Instruction in subjects such as literature, anthropology, politics and philosophy would help future doctors to create and interpret goals of care and to empathetically provide care to patients in a fashion that would allow patients to better understand their health trajectory.

I would introduce a course on palliative approaches to care in the third year of medical school. Students would learn that medical care does not always have to have “cure” as its goal. They would then be thrust onto the wards to learn their trade, reflecting on their previous training and experiences.

The course on palliative care would be revisited early in the fourth year. Fourth-year students would be introduced to hospital-based outpatient clinics for patients with end-stage disease, such as congestive heart failure, end-stage kidney disease and end-stage diabetes.

I would also enhance postgraduate training. I would encourage residents in all training programs to undergo basic palliative care training (e.g., a LEAP [Learning Essential Approaches to Palliative and End-of-Life Care] course) and repeat this at least once before completing their residency. In Ontario, senior medical residents working in specialty clinics would be encouraged to provide house call services to patients registered with the Community Health Links program (perhaps they could be paired with first- and second-year students). Residents in all specialties would be required to undertake at least one month of geriatric training in a geriatric assessment unit. Many of these ideas are probably already in practice, albeit not systematic.

In conclusion, I would want the curriculum for all medical students and residents to place more emphasis on the issue of frailty and the fact that dying is a normal process and to teach trainees that there are times when interventions are inappropriate or likely to cause more harm (disability or premature death) than good. I would expect the Demand a Plan initiative to gain ground as health care providers would come to understand that there is a different, more individualized, way to deliver care: we need to provide “the right care, at the right place, at the right time, by the right person.”

- Ben Robert

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