While the delivery of health care has been changing quickly and in unprecedented ways over the past decade or two, medical education has kept the same basic structure for the better part of a century.
An innovative program for third-year medical students in Fresno is shaking up that system, hoping to fight something long intractable: a shortage of doctors in rural and impoverished areas.
Traditionally, after two years in the classroom, third year students get their first clinical experience by watching residents treat patients in hospital rotations. They usually spend eight weeks observing in internal medicine, six weeks in psychiatry and four weeks in neurology.
The Longitudinal Integrated Fresno Experience, or LIFE, program thrusts medical students into the overlapping disciplines of real-world medicine. Students work directly under a practicing physician in the community. They are assigned to patients and treat them in office settings, clinic settings, hospital settings and with specialists. Students might be in a family practice one day, neurology the next.
“There’s a lot of hands-on exposure. They feel what it means to have their own patients,” said Christina Maser, a surgeon and co-director of undergraduate medical education at the UC-San Francisco Fresno Medical Education Program.
A New Paradigm
Nine students went through the six-month pilot program, which ended in December 2010. Twenty students applied for those spots, a dramatic turnaround for Fresno, which previously had trouble attracting students for conventional rotations. UCSF is one of the top medical schools in the country, and students often choose it because they want to be in San Francisco — not in the Fresno clinical branch.
What they might not realize, said Kenny Banh — an emergency medicine physician and the other co-director of undergraduate medical education — is that Fresno and the surrounding agricultural valley can offer more patient diversity and more training intensity than most big cities.
“We see more patients through the ER at our community hospital per day than the two major teaching hospitals in San Francisco combined,” Banh said.
Also, he said, urban patients tend to fall into one of two groups: privileged with insurance and specialized medical needs, or the homeless population.
The more rural Fresno area, on the other hand, introduces students to a deeper, wider range of patients. The Central Valley is home to a large population of the working poor, as well as a dizzying array of ethnic communities from Hmong to Punjabi to Russian Mennonite. Generation after generation of those displaced by war, famine or other disaster have settled in this agricultural valley.
It is also home to an intense shortage of doctors. There are just 173 doctors per 100,000 residents, the lowest ratio of any region in the state, according to the Central Valley Health Policy Institute.
“The patients that our students see haven’t been to a doctor — not because their symptoms are so rare or because they’re destitute, but because there are just not enough doctors,” said Banh.
“There are things that are hard to teach and hard to learn. You almost have to understand them on an instinctual level,” said Banh. “When the students are here every day facing the disparities in our health care system, seeing the shortage of doctors, developing relationships with people from all these different cultures — the things they are learning are immeasurable.”
As far as things that can be measured, students in the Fresno pilot program fared well in course tests and assessments — on par with or better than their peers who went through conventional rotations.
The integrated, assigned-to-specific-patients model that LIFE offers is rare. There are about 10 such programs in the United States, including LIFE and two others through UCSF.
“It’s a paradigm shift,” said Banh. “This is health care reform for medical education. It’s a way to bring back human connection — a connection to patients and peers beginning in the third year. It’s exciting stuff.”
Please Stay, But If You Should Go …
The medical community in the Central Valley is hoping LIFE serves a practical need, as well as breaks new ground in solving the area’s physician supply problem.
LIFE students can return to Fresno for additional clinic experience during their fourth year and apply for residencies in several disciplines.
Program manager Kasan Jones admits with a laugh that all involved with LIFE know that by simply getting medical students to Fresno, they might choose Fresno for their residencies — and thus give life itself a chance to lure them to stay and practice.
“They get to know the area, form professional relationships. Maybe they meet someone from here, settle down.”
Even if it’s not Fresno they choose, said Maser, the surgeon, the hope is to show students that exceptional medicine is being practiced outside of major-university settings and outside of specialties.
“Our No. 1 goal is to train great physicians,” she said. “No. 2, we’re hoping to attract students to primary care and other areas where there are shortages of doctors. Here, that is every discipline. We have shortages of every kind of doctor.
“No. 3, yes, we hope they practice here, but even if they don’t, we hope that training here, feeling what it is to be truly needed will make them choose to practice some place like this — someplace that really needs a doctor,” Maser said.
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