Making it Real: The Doctoring in Vermont Course
For second year medical students, the Doctoring in Vermont course is an introduction to the real world of patients and primary care practices
- By Ed Neuert
Emily Schloff’s long road to medical school brought her right back to her own hometown for one of the formative experiences in the making of a physician. Beginning in the spring of her first year of studies at the College of Medicine she, like all the other members of the Class of 2015, received an assignment to study at the side of a preceptor, a primary care physician who would introduce her to the world of real patients with real physical complaints, the impromptu “faculty” of Doctoring in Vermont course in the Vermont Integrated Curriculum.
“My preceptor was Dr. Mark Peluso at the Middlebury College Health Center,” says Schloff. Though she grew up in the Addison County college town, Schloff had never met Dr. Peluso before. “Though when I saw pictures of his kids, I did realize I knew them from my days as a lifeguard at the town pool.” All Doctoring in Vermont (DIV) students spend a minimum of four afternoon sessions at their assigned practice in their first spring, and another four the following fall. About 60 Vermont primary care, pediatric, and internal medicine physicians located within an hour’s drive of main campus serve as preceptors to the 113 members of the Class of 2015. “These volunteer faculty members are an incredible resource for us,” says Paula Tracy, Ph.D., professor of biochemistry and director of the Foundations Level, the 18-month initial stage of the Vermont Integrated Curriculum. “They introduce the students to so much of what it means to be a practicing physician.”
“This is the students’ first experience of taking a real history from a real patient,” explains course director Dennis Beatty, M.D., An assistant professor of medicine and a primary care physician at Aesculapius Medical Center in South Burlington, Vt., Beatty has directed the course for the last eight years, having been recruited to the position by the “founding spirit” of DIV, former associate dean for primary care Mildred Reardon, M.D.’67, who first structured the course in something like its current form more than 20 years ago.
“They’ll work with preceptors in taking patient histories and performing physical examinations, and they’ll review their encounters outside the room,” Beatty says. “Students learn about the kinds of things patients present within a given practice, and how the doctor manages multiple patients at the same time. They’ll start to hear some terms and medications they may not yet be familiar with. And I think these things are more meaningful and purposeful when they’re coming up during treatment of a real patient.” Students have worked with standardized patients here on campus beforehand, Beatty notes, referring to the highly trained corps of teachers who simulate patients on-campus in the Clinical Simulation Laboratory. “But this is where, on a regular basis, the students will first start to listen to and put their stethoscopes on real patients.”
For Emily Schloff, as for most other DIV students, that experience started soon after she walked in the door of the Middlebury health center for the first time.
“From day one Dr. Peluso let me go in on my own to see some patients first. He’d say, ‘Go take a few minutes and find out why they’re here.’ Of course, he’d already know why they were here, but I’d have a chance to take a history from the patient on my own, and then go back to the doctor and report — so I learned on my feet to present a patient summary. Then we would go back in together and he would ask some more questions, and then together we would do the physical examination of the patient.”
“It was a little nerve-wracking at first,” admits Joshua Price, who experienced DIV in the office of Joseph Nasca, M.D.’88 in Georgia, Vt. “Halfway through the first day Dr. Nasca handed me a chart and said ‘go into this room and figure out what’s wrong with this person and then come back and brief me.’ That’s pretty nerve-inducing, at first. It’s undeniably different from even the great simulations we have beforehand. You’re not working on an individual skill; you have to start head-to-toe and narrow it down. It’s a challenge and, ultimately, it’s fun.” Price is no stranger to a doctor’s office: he grew up in St. Johnsbury, Vt., where his father, Mark, is a pediatrician.
For medical student Bruno Cardoso, interacting with patients was not a new experience, but acting as a diagnostician was. “I was an Intensive Care Unit nurse for six years before I came to med school,” he explains. “So I’d interacted with many, many patients before. But it was different. I wasn’t asking the kind of questions a physician asks, or looking at the situation the same way.” Cardoso’s DIV preceptor was Emanuele Chiappinelli, M.D.’75, in St. Albans, Vt. Cardoso found that he shared with his preceptor a deep respect for the art of the patient history, and the physical exam. “And I was in awe of the body of knowledge he has from decades of treating patients,” he says “He’d come into the room after I’d taken my history and he’d ask similar questions, but in a much more efficient manner, and he’d get right down to the information he needed to get to, and that I hadn’t elicited from the patient even though I thought I was asking the right questions. It was amazing to watch, and encouraging to think that, with any luck, I’ll gain that kind of experience and ability too.”
After the spring DIV sessions, every student is required to take part in a Clinical Correlation session, where they each pick a case that they have seen clinically, research the case and the condition, and do a full presentation to their classmates. “They’ll talk, for instance, about a patient they saw who had diabetes, and they’ll fully explain the case, and go into the medications that patient takes, and the follow the physiology of how those meds work on the molecular level,” says Beatty.
“I loved taking a patient I’d seen and, for the first time, doing a presentation for my peers. I think it’s valuable to be able to learn that early on,” says Price.
The medical preceptors, in their many practices throughout northern Vermont, see the mentoring experience as a way to contribute to the future of their profession, and an experience that can reaffirm their medical knowledge. “The students really keep me on my toes,” says Peluso, who precepted Emily Schloff. “When you’re teaching something while doing it, you think it through just a bit more, and I find that to teach something that’s complicated allows me to understand it even better. And I have a patient population here at Middlebury that’s mostly college students. They really seem to enjoy having the medical students there, especially the pre-med students. They can connect on a whole different level. I find that UVM med students are very empathetic and ask really bright questions, which is an indicator of how they’ve been prepared.”
“I always start out by telling the student who’s beginning at my practice to read the physician’s oath,” says Joseph Nasca, who precepted Joshua Price. Nasca has mentored DIV students since the early 1990s. “I feel that my patients appreciate having medical students at the practice. I think any chance you have to put these bright young people in front of patients adds validity to what you’re doing,” he says. “I’ll often preface a visit by telling my patient ‘I’d like you to help teach this student with me.’ I believe that’s what they’re doing. And I tell the student, above all, to listen while they’re taking a history or doing a physical exam. I always think that, for a patient, one of the most important things you can hope for when you come to a doctor’s office is that you’ll find someone truly listening to you when you show up.”
At the beginning of the second semester of DIV, students are assessed at the College of Medicine by doing a full history and physical exam with a standardized patient. They receive detailed feedback on this exercise. Near the end of the second semester, they do another such history and exam, and this time they are graded on their performance. Both times they fully document their experience on an electronic health record. “They’ll soon be heading into hospitals to do their clinical clerkships, and they’ll have to use these electronic systems, “ says Beatty. “So it’s better for them to be ahead of the game instead of having to learn how to document while they have all the new knowledge of clerkships to take in too.”
Some medical students return to their DIV practices for extra sessions after the course, or come back for a rotation during their fourth year of studies. And sometimes, for a preceptor, that relationship has even more significance, as is true especially for Joseph Nasca. “Josh’s dad, Mark Price, helped train me 25 years ago, in Burlington, when I was doing my acting internship in neonatal care,” he says. “Mark was a real role model for me, so being able to help train the next generation of that family feels like a real closure of the loop for me.”