Patient-centered learning promotes compassion, empathy, humanism

First-year students listen to patient tell her story.

David Hungate

First-year students listen to patient Frances Barnhart (r) tell her story during a weekly wrap-up. Beside Barnhart is her physician, Renee Beirne, M.D.

The most important item in Room 106 at the Virginia Tech Carilion School of Medicine is a box of tissues.

Room 106, a small auditorium that serves as a venue for lectures and special presentations, is home to an important weekly occurrence for students called Keith’s wrap-up. Every Friday throughout the students’ first two years of medical school, after spending more than eight hours a week learning about a specific patient case, students have an opportunity to meet and interact with the actual patient and the physician who provided treatment.

It’s an honest, often emotional, exchange of the physician’s knowledge, the patient’s experience and feelings, and the students’ inquisitive minds. Few questions are off limits.

“How did you first notice something was wrong with your health?”

“What’s it like to live with partial blindness? With a diminished activity level? With an insulin pump?”

“Were you scared when you learned of your diagnosis? Was your family scared?”

“How do you live your life knowing that your cancer might return?”

In one particular wrap-up, a student questioned a 75-year-old male patient who had been treated for life-threatening cardiac issues complicated by his lifestyle choices.

“How did you stop smoking and drinking alcohol?,” the student asked. The room instantly hushed. All eyes were on the patient.

“I knew if I continued drinking I was going to kill myself or someone else,” the patient said. “Now, I’d like to think I have another good five to 10 years left.”

And this is where the box of tissues in Room 106 becomes important both functionally and symbolically.

“This is the type of medical education you don’t get through textbooks and lectures,” said Richard Vari, the school’s senior dean for academic affairs. “In the wrap-up, we don’t dwell on the science of the disease as much as the human aspect. Probably 2 percent of medical schools across the country are able to do this type of program.”

Patient-Centered Learning 101

The school’s patient-centered learning program uses an educational strategy known as problem-based learning to solve patient cases. Every week for the first two years of medical school, students work in small groups of seven and are assigned a faculty facilitator whose job it is to guide them through a specific patient case.

Even though they don’t have contact with the actual patient until the end of the week, the students approach the case as though they were physicians trying to determine the underlying basic science principles involved in the diagnosis and treatment strategies. While probing the details of the patient’s condition, they learn the clinical science and basic reasoning underlying the case.

Groups meet Mondays, Wednesdays, and Fridays for several hours at a time. But that’s not all. Students spend any number of hours on their own in between group meetings conquering learning objectives as part of the case. Each time the groups convene, members make presentations on a research topic assigned to them two days earlier. By midweek, the group is given faculty-learning objectives for the case to ensure they are on track.

They also attend regular lectures and labs that address the learning objectives for that particular patient case and block of study. For example, the school’s curriculum is divided into different body systems, such as cardiovascular, renal, and endocrine. Each system is a block of study, and each block might have several cases. Year one is focused on normal structure and function of the human body whereas year two features pathobiology.

“The students work their way through the curriculum block-by-block,” Vari said. “The learning is layered – and memorable. It builds a real solid, integrated foundation across the organ systems. Our students go into their clinical rotations in their third year exceptionally well prepared.” Vari is a veteran of the concept of patient-centered learning. The renal physiologist arrived in Roanoke in 2008, when the school was being built, as one of the founding members of the school’s leadership team. He was recruited from the University of North Dakota where he had served as a professor and a leader in starting a patient-centered learning curriculum at its medical school.

In addition, Vari teaches renal physiology, pathophysiology, and also serves as a group facilitator. The Benefits of Problem-Based Learning

Advocates of problem-based learning say it enhances knowledge while fostering important skills such as communication, problem-solving, critical thinking, and self-directed learning. For the Virginia Tech Carilion School of Medicine, the proof is in the feedback.

“Step 1 board scores show that our students are above the national average on the foundation for basic science education,” Vari said. “At the same time, we have lots of anecdotal feedback from our clerkship directors and faculty about how good our students are with patients.”

In addition, feedback from the school’s graduating classes ranks the patient case studies as one of its highest rated activities.

“Problem-based learning is all about realizing what we don’t know and developing a plan for how we’re going to get the information we need,” said Tarangi Sutaria, Class of 2017. “And this requires us to immerse ourselves in our weekly cases.”

The students know the Virginia Tech Carilion School of Medicine curriculum is not typical. They learn about it before even enrolling. During the six weekends a year when prospective students converge on the school for a day of intensive interviews, Vari leads them through a typical patient case. “This is a very different school,” Vari said. “It’s a small school. It’s not for everybody. But this is the way we learn here.”

Cases run the gamut from pediatrics to geriatrics, congenital heart defects, diabetes, and mild cardiac infarctions. One of the many benefits of a small school is that it is able to carry out this unique type of learning.

“The numbers indicate our students are excelling in their medical education in part due to this curriculum style,” Vari said. “We’re helping them not only to be good students, but to become great physicians.”

From Lone Wolves to Team Players

Most of the school’s students arrive without much team experience. As Vari says, they come in as “lone wolves,” smart and competitive. When they arrive, they find that their peers are also smart and competitive. It’s a humbling adjustment for some. The team approach to tackling patient cases week after week helps them adjust to not always being the leader and not always knowing all the answers. Group leaders rotate each week. During each block, students are assessed on their ability to work as a member of a team, to deliver information, and to act professionally.

“I always tried to make sure others in my group could take something of value from my assignments and presentations,” said Frances Bustos, Class of 2017. “There’s a lot of social pressure not to let your group down.”

Bustos said he was familiar with problem-based learning when he arrived but didn’t know how it would be implemented as part of the curriculum.

“It’s a very different way of learning,” he said. “It was exciting and shocking at the same time.” Bustos credits the group work with helping him recall details of specific illnesses and diseases.
“On more than one occasion,” he said, “our patient cases helped me remember information while working on another case or in rotation.”

That’s a Wrap

During their first two years at the Virginia Tech Carilion School of Medicine, students will study 56 patient cases using the small group, problem-based learning method. That’s 56 Carilion Clinic patients who volunteer each year to tell their story and answer questions from a group of students. That’s 56 patients who decide helping to train future doctors is relevant and important. That’s 56 patients who believe in the future generation of health care providers.

“Many of these patients return year after year,” Vari said. “They love the wrap-up.”

In 2011, an endowment was established for the program for the specific purpose of helping these patients with transportation or other expenses they incur when participating in the wrap-up. Named Keith’s Wrap-Up after a young patient, the program was made possible through a gift from the patient’s family.

“Some wrap-up patients want to share their story, but they come from modest means,” Vari said.

“Thanks to the this gift, we’re now in a position to make them feel a bit more appreciated and can continue offering this part of our curriculum that really makes us special.”

“Patients telling their stories gives cases a whole new dimension,” Bustos said. “By Friday, we know a case inside and out on a scientific level. Then we get to hear it from the patient’s perspective.” Vari said one thing that becomes apparent is that patients love their physicians, and physicians care about their patients.

“There are so many things that come out of a Friday wrap-up,” he said. “It’s phenomenal, really.”

And it all happens right there in the front of Room 106—the one with the tissue box.

By Catherine Doss

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The Virginia Tech Carilion School of Medicine has distinguished itself as a community of learners who come together in small groups for problem-based learning using actual patient cases. Watch the video to learn more.