By Sandhya Chandrasekharan (entering class of 2013)
This past year, Mount Sinai MSTP Associate Director Talia Swartz spearheaded a new monthly MD/PhD clinical case series for students to hone their clinical reasoning and problem-solving skills. The sessions have been well received, and reflect some of the exciting changes being conceived and implemented in the physician-scientist training framework.
Although Swartz officially took on the role of associate director less than a year ago, she has been closely involved with the program for years. “I went through the program here myself, so I am aware of a lot of the challenges students should anticipate during the program at this institution and as they apply to residencies and consider future career paths. There are a lot of nuances to this training compared to that of our colleagues with different interests and goals, so understandably, we need a special sort of guidance.”
To this end, Swartz has been working very diligently to ensure a more seamless transition from the PhD phase to the clinical years. Notably, she reworked the clinical refresher course to better suit students’ needs. She explains, “The idea was to give people a handle to recover any losses from their preclinical years, and I think the course is now starting to more quickly refresh the knowledge of the past while working toward developing beneficial skills moving forward.” She also has been looking into improving the efficacy of the faculty advising system in place – “There are many amazing faculty advisors who continue to be invested in the MSTP. By standardizing the advising system, students will know exactly who to turn to for information on career choices and options ahead.”
As alluded to earlier, Swartz’ most recent undertaking has been the clinical case discussions she has organized. “An overwhelming majority of students felt they had little clinical exposure during their PhD years. So we have had one student each session choose a case from the NEJM Case Records of Massachusetts General Hospital, and provide a basic overview of the topic… Rather than coming up with the correct diagnosis per se, the idea of these sessions is to think through a broad chief complaint and start asking questions like – What should we be thinking about? What parts of the history do we want? What parts of the physical exam would we look for? Slowly, but surely, the answers to these questions help the group narrow down the possibilities and move diagnoses higher and lower on their list of differentials.”
Robert Rifkin, MP3, offers his perspective on the sessions, “I think the presentations, discussions and attendance have been great. We have been using NEJM case reports, which are often “zebras”, forcing the students to work to emphasize more bread-and-butter diagnoses. For example, I had a case of a woman with heart failure due to Libman Sacks endocarditis…, which is not a case you are likely to see on a daily basis, but… I tried to emphasize how to think about dyspnea in a young person. Dr. Swartz has provided great comments during the sessions, keeping us focused with her clinical experience. The students have been very interactive and engaged. I think it is a great program.”
Swartz notes that the current discussion format has evolved much from its inception about a decade ago. “There used to be an evening clinical case discussion like this back when I was a fellow. A member of the house staff would precept, and a student in the middle of his or her PhD years would present a case. Everyone who attended would then chime in about their thoughts on what to do next, what questions to ask, and possible diagnoses… The next generation of these discussions became integrated into the program-wide monthly Medical Scientist Research Seminar (MSRS), where a senior student in his or her third or fourth year of medical school would present a case, followed by a research talk from a senior PhD student planning to defend in the next few months… But this past year, MSRS shifted away from this structure to allow time for program updates from the directors.” And this was when the clinical case discussions, as they exist now, were born.
Swartz admits that the previous MSRS format was not the most conducive to a clinical reasoning paradigm. “MSRS offered a mixed audience of students with all levels of expertise and interest… and because of this, I do not think that people were very focused on what the objective of the session actually was.”
The new structure of these discussions has addressed these issues. “These sessions have had a focused group of approximately 20 students, where everyone is more or less at the same stage in their medical education. While the sessions are open to all MSTP students, the core group has mainly consisted of students in their PhD phase, evenly spread across the four years, which has allowed the sessions to achieve the goal of providing a platform for medical dialogue to students who would not otherwise have access.”
Although Swartz had initially planned to implement an interactive polling system to encourage audience participation, she reveals that there has been no need to do so. “It’s funny – people have generally been comfortable with voicing their thoughts… The polling system had been intended for people who did not feel comfortable volunteering answers, which actually does happen in case discussions amongst clinicians. But in reality, there will be times when you do not know the answer and there is no shame in that.”
Importantly, the series has also offered opportunities for students to teach their peers and colleagues – not unlike presentations they will be expected to give during residency and beyond. Benjamin Laitman, MP2, says, “Both informative and interactive, the sessions have provided an avenue for the audience to refresh key clinical concepts and the presenter to really delve into specific disease processes while getting an opportunity to teach… Who doesn’t love free food and learning in a non-threatening environment?”
Swartz already has big plans for how to grow these discussions into a platform that effectively includes the program at large. “The next generation of this series is going to be a broader and larger one. Intertwining clinical cases with research problems, and learning how to test hypotheses based on medical problems in the lab is relevant to every MSTP student. We envision an integrated session involving junior and senior students, as well as interested house staff and faculty. All these individuals would come together and talk about cases and the pathophysiology and science behind them, followed by a panel of experts offering their perspectives. This is a work in progress, so stay tuned!”