SITTING IN ON A DOCTORING 3 CLASS one Thursday morning at the David Geffen School of Medicine at UCLA, one quickly realizes that little of the conversation can be found in any textbook.
On this day, in a small room that barely contains the rectangular table around which sit eight students, the topic is germs. Guided by two faculty facilitators, the young men and women engage in a free-wheeling discussion in which they share the experiences they’ve had on hospital wards – and, in moments of digression, in fast-food restaurants (you don’t want to know). Like Las Vegas, the understanding is that what’s said in this room stays in this room, and the conversation is remarkably frank. Students who have learned in previous courses and on their clinical rotations how things should be are now talking about how they really are. Each has some war story to tell of providers they’ve observed who remove their masks around sick patients or don’t wash their hands before leaving a patient’s room. At a time when the H1N1 flu virus is spreading rapidly, the students are resigned to the reality that putting themselves at risk of infectious diseases is a hazard of the job, and that when they do get sick, the culture demands that they will have to muddle through.
No topic is out of bounds in Doctoring 3: Abortion, medical marijuana, end-of-life care and racial/ethnic and gender stereotyping are just a few of the issues that will be discussed during the academic year. But something else is different about this and the eight other Doctoring 3 groups that meet each week: Half of the students in the class are from the UCLA School of Nursing.
The Interprofessional Seminar/Doctoring 3 course groups third-year medical students with second year master’s students who are preparing to become advanced-practice nurses (APNs) in the School of Nursing’s acute-care and oncology nurse practitioner/clinical nurse specialist programs. While a growing number of institutions have moved toward interprofessional education and team-building exercises, there is little precedent for what Doctoring 3 did in 2009-’10 – for the first time bringing graduate nursing and medical students together as equals, in a required course for a full academic year.
The course is designed to provide an opportunity for students to discuss issues that are difficult to address in other parts of the curriculum. But with the introduction of advanced-practice nursing students, it is serving another important purpose: breaking down traditional barriers among individuals who are increasingly working together in multidisciplinary teams.
“If we want people from different health professions to understand each other and not view one another as potentially antagonistic, we need to have them grow up together as students,” says Margaret Stuber, M.D., the Jane and Marc Nathanson Professor of Psychiatry and director of the 20-year-old Doctoring Program at UCLA, which focuses on psychosocial, ethical and interpersonal issues and competencies.
WITH THAT TEAM APPROACH as the premise, an Interprofessional Education Task Force with representatives from the medical and nursing schools had been discussing potential ways to bring the two disciplines together. Integrating APN students into Doctoring 3 seemed an ideal fit. “Medical students and APN students have a lot in common,” notes Dr. Stuber, who developed and oversees the Doctoring 3 course. “Both groups are going to be writing orders and making clinical decisions, and this is a time in their education when they are learning how to do that.”
Courtney H. Lyder, dean of the School of Nursing, believes such collaborative efforts represent the future of medical and nursing education. “No two groups of health professionals are more interrelated in practice,” he says. “This innovative program starts the process where it belongs – in the classroom.”
Doctoring 3 cohorts have eight students who remain together throughout the year. The Thursday groups are evenly split between medical and nursing students; each group also has two faculty “tutors” – a physician and a nurse – who facilitate the meetings.
Bringing the APN students into the mix adds an important perspective to the discussions, says Christopher Harris, M.D., associate professor of pediatrics and one of the tutors. “Many of them have been bedside nurses before they entered the graduate program at UCLA, so they have a lot more clinical experience than the medical students,” Dr. Harris says. “Because they’ve been in the trenches, they tend to be able to speak with more authority about what goes on in hospitals than the medical students can.”
After the concept was pilot-tested with a dozen nursing students who participated in Doctoring 3 for a single quarter in 2008-’09, it was apparent that the integration was valuable – and much-needed. “One of the things the nursing students told us after the experience was that they had learned that the medical students are actually pretty nice – which, unfortunately, was a surprise to them,” Dr. Stuber says, laughing. Likewise, she adds, few medical school faculty – much less medical students – are versed in the increasing scope of a nurse practitioner’s or clinical nurse specialist’s practice. But as they engage on the topics of the day, the students are also gaining an appreciation for the training of their counterparts and the approaches they bring to clinical settings.
“I feel the medical students understand us much better now – what our role is and how we contribute to healthcare,” says Liz Lizaso, a student in the School of Nursing’s dual clinical nurse specialist/acute-care nurse practitioner program. Lizaso, who had 13 years of experience as a registered nurse prior to starting her graduate training, says Doctoring 3 has also helped her overcome barriers she once felt when communicating with physicians.
“Nursing and medicine are often viewed as, if anything, in opposition,” says Richard Fogel, another acute-care nurse practitioner student who was part of the Doctoring 3 course. “It was strange at first to be in the same room with medical students talking about controversial subjects, and we didn’t know what to expect. But the most surprising part was how much common ground we had on most of the topics.”
To Fogel, it was just as revealing to get to know the medical students on a human level as it was to learn that they shared many of the same views on patient care as the nursing students. “My impression of them totally changed when I realized they had the same struggles and anxieties about what they’re going through as we do, along with the same feelings of triumph when things go well,” he says.
GIVEN THE PROVOCATIVE SUBJECTS that are broached, it’s not surprising that when the eight students and two tutors get together behind closed doors, the conversation is always lively. While there are plenty of important facts to be learned by would-be physicians and advanced-practice nurses – evidence-based knowledge about when to treat and what the best medications are for given conditions, for example – one reason Doctoring 3 is an ideal setting to mix medical and nursing students is that it covers clinical aspects that aren’t so black-and-white. “It’s about the context – both internal and external – in which we make decisions,” says Dr. Stuber. “What role do our biases and emotional responses play, and what are the legal, social and economic contexts in which these decisions are made? All of these can have an effect, and are thus important to learn.”
To prepare for a session’s directed topic, reading materials are divvied up, with each student responsible for reporting to the others on his or her tutorial. At the height of the debate on healthcare reform in the United States, for example, each student was charged with learning about a different country’s system to prepare for a discussion of the pros and cons of other models vs. the U.S. system. Students also share paragraphs they write about their own experiences and views vis-à-vis the week’s topic. For the session covering hospice and palliative care, tutorials covered subjects that included grief and bereavement, pain, hospice care, complementary and alternative medicine, and final hours of living. Students reflected on their own experiences with end-of-life care: Was there a timely discussion about transitioning from curative to palliative care? Was there adequate attention to pain, fatigue, appetite and nausea? What ethical or spiritual issues were raised?
Students also examine their personal biases: Do they have preconceived notions about patients based on gender, ethnicity or appearance? How do those stereotypes affect their approach to care? A session on conflict of interest touches on everything from the impact of direct-to-consumer advertising to whether something as seemingly innocuous as using a pen with the name of a drug company might influence prescription orders. When abortion is the topic, students delve into difficult questions such as what they would do if they personally opposed the procedure but believed in a woman’s right to choose. Would they learn how to perform abortions or avoid any abortion-related interactions? “We’re stretching the concept of what it means to be a clinical decision-maker,” says Dr. Stuber.
The discussions also turn to personal interactions and conflicts within the healthcare team. Students share times when they felt uncomfortable after observing an attending physician not doing a good job of listening to a patient. They open up about experiences when they felt misunderstood or disrespected, and how they responded. When Lizaso described an incident involving a resident, the medical students helped her to better understand the resident’s perspective. “We’re always going to encounter conflict, but it’s helpful to hear what other people are going through and how other students overcame their conflicts,” Lizaso says. “It allows us to use that information in practice.”
THE STUDENTS LEARN from the start that Doctoring 3 provides an environment for no-holdsbarred interactions, a place where they can feel safe in expressing concerns and vulnerabilities. “Some of the discussion is sensitive and doesn’t necessarily follow the party line, so it’s understood that what’s said will not leave the room,” says Maggie Dewan- Smith, a lecturer in the School of Nursing and one of the Doctoring 3 tutors.
Like the students in Doctoring 3, Dewan-Smith keeps a busy schedule: In addition to lecturing at the School of Nursing, she works half-time as a nurse practitioner in UCLA’s Adult Non-Invasive Cardiology Lab and is in the U.S. Air Force Reserve. Nonetheless, she volunteered to serve as a tutor in the pilot year and was happy to play the same role when the program was expanded this year. “It’s just so interesting,” Dewan- Smith says. “We have wonderful, lively discussions. We laugh – it can be a great stress reliever. And a lot of trust builds up among the members of these groups.”
Doctoring 3 comes at a key moment for all of the students – a time of both transition and stress. The APN students are in the process of making the shift from following orders to writing orders, a significant change in how they conceptualize their role. They are giving grand rounds for the first time and completing their academic and clinical studies while preparing to take their comprehensive exams. Similarly, the medical students, after two years focused heavily on classroomand laboratory-based education, are for the first time part of hospital teams where clinical decisions are being made that can have life-or-death implications. It’s the type of intense emotional experience for which no lecture can adequately prepare students.
But the course provides a welcomed respite. “We’re in a year in which we don’t get much of a break away from our work, and this gives us a chance to step back and reflect on what’s going on and how it’s affecting us,” says Vatche Tchekmedyian, a medical student in the Doctoring 3 course. “It’s great to go through that with the nursing students, and it felt very natural from the start.”
Dan Gordon is a regular contributor to UCLA Medicine.