Yale Bulletin and Calendar

December 7, 2001Volume 30, Number 13

Sarah Nikiforow, a student in the M.D./Ph.D. Program and a six-year veteran at the Wednesday Evening Clinic, examines patient Mary Jacob, who has cerebral palsy. "Don't stop exercising," she told Jacob during this visit." That's what's keeping you in such good shape." Nikiforow and other medical students have the opportunity to establish ongoing relationships with patients at the clinic.

Medical students provide first line of care at clinic

This article is adapted from "Learning for the Long Run" by John Curtis, which originally appeared in the Spring 2001 issue of Yale Medicine magazine.

Dr. Kathleen White, director of the Wednesday Evening Clinic at Yale-New Haven Hospital, likes to tell the story of the clinic patient who worried that her doctor was not there to care for her.

Although surrounded by people in white coats with stethoscopes dangling from their necks, the patient was concerned because none of them was the person who knew and understood her medical history and with whom she had established a bond. They were doctors, but they were not her doctor. Her doctor was a student at the School of Medicine, working under the supervision of attending physicians at the clinic, where she had been receiving her primary care.

For a quarter of a century, the clinic has provided care to the New Haven community while giving students a chance to practice "longitudinal," or long-term, medicine and learn how to connect with their patients.

"This is the only place in med school where you get to see the same patient again and again," says Frances Balamuth, who was the clinic's student director last year. That post is held by Stephanie Eisenbarth this year.

The women note that the opportunity to build a relationship with a patient is no small thing. Typically medical students spend no more than four weeks on each of their clinical clerkships. That time is often spent watching residents work, with an occasional chance to practice hands-on medical care under supervision. In general, at Yale and around the country, medical students have few opportunities to follow patients over time.

At the Wednesday Evening Clinic, however, the students are the first to see patients, the first to take their histories and the first to conduct physical examinations. "The whole idea of longitudinal care struck me as being an awfully important one," says Dr. John E. Whitcomb '77 M.D., one of the clinic's earliest student participants, who now practices emergency medicine in Milwaukee. "I wanted to have a relationship with people."

Dr. Lynn E. Sullivan '96 M.D., who spent 18 months in the clinic when she took time off from medical school to have her second child, says, "The students are just aching to see patients and start being doctors. This is a way in which they can do it in a very organized, safe and nurturing environment." Sullivan, now an assistant clinical professor of medicine at Yale, is also one of the clinic's attending physicians.

The clinic started in the mid-1970s when students who wanted longitudinal primary-care experience were invited by medical school administrators to organize their own program, recalls Dr. G. Morris Dillard, who helped found the clinic and served as its director for over 20 years. "They gave the students the responsibility for forming the clinic, running the clinic and obtaining the appropriate support from the faculty," he says.

Students found space in the Primary Care Center at Yale-New Haven Hospital, which was closed evenings, and enlisted the support of physicians, nurses and support staff willing to volunteer their time. "At first it was very difficult to get patients," says Dillard. "But we were the only clinic open at night in the hospital. We were the first clinic to have an on-call physician. We could be contacted 24 hours a day, seven days a week, every day of the year."

Then, as now, the patient population came largely through the Primary Care Center, the hospital's emergency department and self-referrals. Although the clinic had the virtue of being open at night, many patients were initially reluctant to use its services. "The students endured the discrimination of being a student clinic, despite the presence of [attending physicians]," says Dillard, who, along with clinic director White, leads a rotating cadre of faculty and community physicians who supervise the students.

The clinic's staff credit Dillard not only with founding the clinic and keeping it going over the years, but with making it a welcoming place to learn medicine. "He has made it a very warm, friendly and cohesive group of people," says White, who succeeded Dillard as the clinic's medical director five years ago.

The clinic's caregivers get to know each other over dinner every Wednesday. They take turns providing the evening meal, often a stack of pizzas on the conference room table. As they eat, students and faculty discuss clinic business, such as a plan to obtain free samples for their patients from pharmaceutical companies. They may review an unusual case. Often the group breaks up into two or three smaller sessions for case reviews with an attending physician. By 6 p.m., the students are ready for the two to four patients that each of them will see.

"We do a thorough history," says Nir Modiano, a sixth-year student in the M.D./Ph.D. Program. "We do a physical exam and formulate our own thoughts, then present the patient to the attending." The student returns to the examination room with the attending physician, who may obtain more history or conduct another physical exam. "The student may have already come up with a plan of treatment," says White, "and the attending will verify specific exam findings and confirm the plan or alter or add to it."

Their cases run the gamut -- a 76-year-old woman with a lung obstruction, a patient with diabetes, a woman suffering from osteoporosis, a patient with chest pain, a refugee from Sierra Leone with post-traumatic stress disorder.

One evening Sarah Nikiforow's patient was Mary Jacob, a 35-year-old with cerebral palsy. Nikiforow, who is now in her ninth year of the M.D./Ph.D. Program, has six years of experience at the clinic, making her the facility's veteran. Jacob, who has arthritis and occasional muscle spasms, has been her patient for years. "Don't stop exercising," Nikiforow tells Jacob after a physical exam. "That's what's keeping you in such good shape."

Ongoing relationships with patients are only one of the benefits of the clinic, say the student participants. Another is the chance to work with a network of physicians they will see repeatedly over the course of a year or longer.

During their time at the clinic the students observe a variety of styles, including Dillard's. "He steps back and does nothing at times and the students take over and make a decision," says White. "He has made it a very academically challenging place."

Such longitudinal clinics, explains White, provide an obvious benefit to medical students. "You watch them start as clumsy ducklings and then blossom into competent and caring clinicians."

-- By John Curtis


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