For nearly a century, the third year of medical school has been a pivotal point in training, a crucial step in the development of professional skills and attitudes toward patients. Recently, however, the tradition of monthlong “rotations” – a speed-dating introduction to the major disciplines of medicine and the issues patients face – has come under fire.

During their third year, medical students are under constant pressure to perform for an ever-changing group of senior physicians, who in turn must evaluate the students based on brief interactions. Sailing through as many as six disciplines in just under a year, students have opportunities for only transient relationships, garnering mere snapshots of their patients’ illnesses and lives.

Not surprisingly, studies have shown that these experiences result in “ethical erosion.” Students’ sense of empathy and bedside manner deteriorate, and many begin to refer to their patients not as people but as diseases, that dehumanizing shorthand of the wards.

Now a growing number of educators are working to reinvent the crucial third year of medical school. A recent article in the journal Academic Medicine explains how one program has successfully eliminated traditional block rotations, promoting instead yearlong relationships between students and their patients and capitalizing on the patient-centered values and humanistic impulses that led the students to medicine in the first place.

Since 2004, the Harvard Medical School-Cambridge Integrated Clerkship has assigned every third-year medical student to a “panel” of up to 100 patients to care for over the course of the year. Students see their patients in the clinics of the Cambridge Health Alliance health system where the program is based, but also follow and assist with any outside consultations, admissions to the hospital, operations and even home visits. During the year, students are also required to shadow several assigned preceptors, senior physicians from the major specialties, in their clinics every week.

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In a study published this year in the journal Health Services Research, researchers analyzed the results of a survey that asked nearly two million patients how they felt about their hospitalization. Known as the Hospital Consumer Assessment of Healthcare Providers and Systems, or Hcahps (pronounced “H-caps”), and administered to patients within six weeks of discharge, the survey consists of 27 questions about topics ranging from communication with nurses and doctors and responsiveness of hospital staff to general cleanliness and noise levels.

When the researchers divided the questionnaire results by the patients’ sex, they discovered that men tended to be more positive over all about their hospital experiences. Women were less satisfied with staff responsiveness, their discussions with nurses, communication about medications and discharge plans and the general conditions of the hospital. Among men and women who were older or felt sicker, these differences were even more pronounced.

“What patients require when they are ill and feeling vulnerable is not the same,” said Marc N. Elliott, the study’s lead author and a senior statistician at the RAND Corporation in Santa Monica, Calif. “What’s becoming clear is that we are not meeting the needs of female patients.”

In some cases the extent to which male and female patients differed in their satisfaction levels was substantial, surprising even the researchers. “There was a fairly consistent gender gap,” Dr. Elliott said. “But some of the differences were on the same magnitude as what you might see among patients from different ethnic groups or widely disparate socioeconomic backgrounds.”

One of the more marked differences was the amount of information about medications or discharge plans that patients needed to feel sufficiently informed. Women generally wanted more information than they received, while men were satisfied with what they were told. There were also considerable disparities between men and women regarding cleanliness, with women inclined to be less satisfied with the hygiene of hospital surroundings.

The findings from this study underscore how complex addressing quality and patient experience can be. Currently, most health care improvement efforts tend to treat patients as a monolithic group. It’s an oversight that can be attributed, at least in part, to the relative paucity of research and data on the patient experience.

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There were so many questions, yet little time to answer them all. Here’s your chance to continue the conversation with Dr. Walsh. Post your questions here and get a response from Dr. Walsh.

The webinar discussed adding outcome measurements to simulation for assessment of learning or competency. The contributions of scenario validity and reliability to accurate measurement, methods for evaluating available tools, and how to develop a measurement rubric using the MASTER method was introduced. Dr. Walsh also presented a rationale for reaching consensus in simulation education evaluation.has enjoyed nursing as an educator in hospital and academic settings, and performed bedside nursing in intensive care units for many years. Dr. Walsh became involved in simulation education in 2006 at Clayton State University, and incorporated simulation in her doctoral research at Georgia State University, in Atlanta, GA, studying the effects of pattern recognition-based simulation on symptom recognition of myocardial infarction, critical thinking, clinical decision-making, and clinical judgment in nursing students. As Director of Simulation at Clayton State she oversees incorporation of simulation into the nursing curriculum to achieve program outcomes with emphasis placed on reliability and validity of simulations as a platform for competency evaluation.

Dr. Susan A. Walsh

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