Hands-On Learning Helps Medical Students Put Patients First

TCU and UNTHSC School of Medicine’s Dr. Stephen Scott discusses the school’s integrated approach to education.

Hands-On Learning Helps Medical Students Put Patients First

TCU and UNTHSC School of Medicine’s Dr. Stephen Scott discusses the school’s integrated approach to education.

At the TCU and UNTHSC School of Medicine, Scott is senior associate dean of educational affairs and accreditation, professor and chair of medical education, and director of longitudinal integrated clerkship. Before joining the new school, Scott worked at Weill Cornell Medicine-Qatar.

The new school will abandon the big lecture. Why?

Dr. Stephen Scott explains how the TCU and UNTHSC will abandon the big lecture template. Photo by Glen E. Ellman

Dr. Stephen Scott explains how the TCU and UNTHSC School of Medicine will abandon the big-lecture template. Photo by Glen E. Ellman

If you hearken to the past, a lot of physicians were trained in a model where they sat in classrooms from 8 a.m. to 5 p.m. for two years without seeing any patients, but there is a more efficient way to learn, using deliberate practice. If we really do a good job of integrating and thoughtfully pulling all that together, students will learn faster. And it sticks. It’s the idea of deliberate practice. You have to be able to practice a skill to get better. And so much of what we do in medicine, it’s not just about the knowing, it’s about applying the skill.

In these shorter preclinical curricula, or these longitudinal models, there already has been some nice research work to show that students actually perform equally well or better on standardized tests and licensing exams. But I think more importantly, this model has some demonstrated advantages. For example, students who learn in this way and work over time with teams and patients are more patient-centered. They demonstrate higher empathy scores on standard skills, and they contribute more to the practice of medicine.

You’ve worked in Qatar and in Russia. What insights did you acquire in working with those populations about healers, culture and communication?

One thing that is universal is that people want to be cared for. It doesn’t matter how fancy or sophisticated we get with technology and all our advances in medicine, there will always be the role of the physician as a healer, someone who connects, makes sense of illness, brings meaning to that experience, brings hope. That’s universal.

You have to be really curious about every patient in front of you. You cannot assume anything based on skin type or language or anything about them. You need to be curious. But I think more than anything, knowing the world we live in, it really helps you to be thoughtful and to recognize that patients have their own stories. And the starting point is always to learn their story.
I think that’s the most important thing.

You are a pianist. How does music shape your work in medical education?

In music, you get regular evaluation of how you’re doing. It’s really personal and intimate feedback about what’s not going well, and what you need to do to get better. There’s a relationship between the student and teacher that is essential. A student has to trust that the teacher is going to help him get where he wants to go. The most successful educators engage students and set really high expectations but also demonstrate that they believe their students can do it.

Music has shaped me as an educator as much as anything else, and I had the gift of some great teachers along the way. I saw some really great modeling. It’s funny to me how often I have caught myself speaking with a student not about any music lesson, but where I’ll sort of say something or take an approach to something and realize, well, that’s spooky because that’s what Mrs. Wood [music teacher] said to me at one point, or I remember a moment when I was the recipient of that kind of framing or feedback.

In this day and age, I think sometimes people don’t see the value of just plain hard work. You don’t just sit down and play a Beethoven sonata on day one. Maybe not even in the first three or four years. There’s a lot of deliberate practice that has to happen to get to the place where you are comfortable and can do that well, but it’s totally achievable.

I think we’re all a little bit too prone to say when we see someone who does something really well that they are just totally gifted or such a natural. We sort of excuse them from all the hard work, the hours they spend in the practice room by themselves, the teacher who provided some hard feedback, and then they go back and practice some more, you know, battle it out.

At the center is just the labor. This is where I get the idea of deliberate practice, and what it takes; the kind of investment required. It’s a combination of a teacher setting high expectations and saying that I believe in you, and then the student following through with the practice; the work. No one can do the practice for you; there’s no magic pill.

Can you give an example of using music to work with different kinds of students?

I think as an educator, [music] has taught me a lot about the value of connection and the value of vulnerability and coaching. I’ll start with an educator’s point of view: Sometimes you have a set of students who come into the classroom who maybe has done really well their whole lives, kind of done it on their own, gotten the grades, checked all the boxes.

Dr. Stephen Scott is a trained pianist and talks about the overlap between music and medicine. Photo by Glen E. Ellman

Dr. Stephen Scott is a trained pianist and recognizes the overlap between music and medicine. Photo by Glen E. Ellman

Then you have another set of students who maybe has done a lot of the same things but also has had, either because of a sport or because they play an instrument, or because of some work experience, they’ve had ongoing intensive coaching and feedback; they’ve gotten a lot of advice over time about how they perform.

As an educator, the students you would rather teach, or they are more fun to teach, is the second set because they get it. They are open to feedback; they want to know how to get better. They realize the value of feedback and they’ve seen the successes that come with that experience.

Whereas the first set of students, they can be much more resistant. They talk about the problem is the test, not them. They come with all kinds of defenses that make it really difficult sometimes for them to change or to adapt, or to learn. 

How do you see the connection between the humanities and the development of physicians?

Music is a very abstract but deeply personal medium. People connect with music. Other aspects of the humanities are about making that connection: when we write our story, when we try to express ourselves in words, or a painting, or when we simply read the stories of others. Now, we know that develops many, many things, but among them is the ability to empathize and think about others and their experiences; that’s really critically important. It was incredibly valuable for me to invest that time in music, and I hope that it has given me some additional reserves or skills as a physician.

How will the medical school’s curriculum integrate the use of new technologies, such as virtual reality, in the learning process?

It’s not technology for the sake of technology, or just some shiny new thing. It’s using technology for the sake of learning. The standard is to use the most efficient way for a particular concept, don’t spend a gazillion dollars to make a five-minute movie when a one paragraph summary is what really works best.

For example, when you think about the complexity of the heart as an electrical system, how do those beats originate? If you can see in a few minutes with a 3D manipulate bubble model, sort of turn it upside down and inside out, you can imagine that’s so much more efficient than just seeing a static picture or a drawing.

And then you start to add all these things that are happening on a microscopic level, the physiology and the pump and the electrical system and the ability with the hollow anatomy to just sort of peel off layers of the heart to see into those vessels and inside the coronaries and see those valves and how they’re working and how they just click.

It’s like when you try to put together your furniture. You see that schematic, which for some people works but for others it doesn’t. It takes too much time to figure out. I think most people say those drawings are not intuitively obvious. The little parts don’t fit. The screws don’t match. But if you had a little 3D image to show how all the pieces fit together, maybe it would be obvious how it goes together.

So back to the heart and the physiology, if you have low potassium, what happens to the electrical system? You can simulate that condition. You can show how things can change from moment to moment. This is not a static image or an abstract concept. You can model different outcomes. You can make mistakes in these environments, and they are safe environments for you to see what happens. You make your mistakes before you deal with the breathing person.

Medical students will work with patients from their first year. Explain how that works.

The importance of doing these robust clinical skills courses from the beginning and applying what they’ve learned immediately gets the students engaged in the practice of medicine. Those first couple of weeks, they might not be doing physical exams because they have not been taught that yet. But they can participate in a very robust approach to the interview. They can listen to a patient’s story, getting all the information, and they’re engaged from the get-go; they’re practicing.

What is the importance of the longitudinal integrated clerkship approach? 

In medical education in the past, the model has been to do six weeks in pediatrics, where you spend two weeks in the hospital, you spend two weeks in the outpatient setting, and maybe two weeks in the nursery. And that’s how you learn pediatrics. And then you completely switch and you go to internal medicine, and you do that for a couple of months.

You’re switching all the time, so you have these very brief, intense encounters, but you have a new team, new physician and are working with new patients almost every other day. It has worked — I don’t want to say that it hasn’t. People have figured out how to be good doctors. But we do know that there’s a high cost; there’s a loss of empathy over time. These relationships are very temporal, short-term. And even though it’s fairly teacher-centered in terms of maybe easier to schedule people, it’s not great for learning.

In the longitudinal integrated clerkship, students are doing learning and practicing for an extended period of time. They are with the same team working with that same mentor. The quality of that feedback gets better, because they get to know you better over time. They see how students are doing, and they see how they are improving, and by the end of a 40- or 50-week time period, it’s just a much richer opportunity. Students learn better because they see the same patients over time.

Dr. Stephen Scott talks about the importance of medical students working with patients early in their education. Photo by Glen E. Ellman

Dr. Stephen Scott finds the importance of medical students working with patients early in their education. Photo by Glen E. Ellman

It’s not Ms. Jones today, in this 15-minute period, and I never see her again. It’s Ms. Jones comes back in a couple of weeks, and I see what happened. And six weeks again after that. Students really get an idea of not only the medications prescribed but also what happens to her blood pressure; what happens in her life and what challenges she might have, such as she couldn’t get the prescription filled. And, you know, it’s the way that we actually practice medicine. These are the things that we do day in and day out as physicians, so it gives students, I think, a much more connected and meaningful experience.

Our clerkship director group planned this whole curriculum. And so often in medical school, all those directors would be siloed in their disciplines, doing their own thing. Now, they plan and integrate to pull it all together. So much of health care nowadays is a team effort, so it’s important to mirror that reality and leverage that and do that well in the education part.

In the fourth year, the final course is about the art of medicine. Why is this the last course?

The values that drive what we do at the school, you can’t just say them in the first week and then not live them, right? You have to live and do it. As faculty we have to be models. Students have to experience that this is the real deal. The process of forming an identity as a professional and as a physician, we know that happens over time, and it requires some reflection and thought. Some of us are more inclined to do that on our own. But all of us probably don’t do it quite enough. We don’t take those moments to pause and think, is this meaningful? Is that what I’m supposed to be doing, how I want to be doing it?

It’s about getting our students ready for all the different settings that are coming next. It’s a continuation, to give students an opportunity to go back where they started and reflect on these four years. You are about to become a licensed clinician — where do you want to go? Let’s be sure we engage in that conversation. But again, it will be in context with everything that they’ve learned. The final course is not separate, not like a little piece of icing. It’s part of the core identity of who we are, so embedding that course, again integrating it, we are going to start the conversation from day one.

Describe a mentoring experience that has stayed with you.

During my residency, in Seattle, one of those things I didn’t really appreciate at the time as much as I do now was that they had a clinical psychologist follow each of us around one day, a month in clinic, and it was the same person for a whole year. Then you would get somebody else in the second year and another person for the third year, and it felt very benign that the clinical psychologists were just there. We would walk out of a patient’s room and the psychologist would say, “Hey, did you think about X?” As I reflect on that now, a lot of the things that I learned from those encounters were about building a skill set that wasn’t necessarily about drug A or B, but about what’s going on in the room there; are you paying attention to the interaction? And the psychologist would say, let me give you some more tools or tips or tricks, if you want to make another choice the next time that particular challenge comes up.

— Norma Martin

Editor’s Note: The questions and answers have been edited for length and clarity.