Third-year WSU medical students arrive on the Vancouver campus for their clerkships.
In June, 16 students from WSU’s first medical school class arrived in Vancouver for their 10-month clerkship. It’s a big step on a likely 7- to 10-year journey to become doctors. For Vancouver and WSU’s four-year-old Elson S. Floyd College of Medicine (ESFCOM), it is part of an innovative redesign of medical education to address a growing need for physicians in underserved communities.
In a traditional clerkship, third- or fourth-year medical students rotate from one clinical specialty to another every few weeks. They work with experienced practitioners in each field, one specialty at a time.
WSU medical students spend their third year in a Longitudinal Integrated Clerkship (called LIC). Instead of a sequence of trainings, students work with seasoned practitioners in six different specialties, and in hospital and outpatient settings, side-by-side throughout the year. They might spend a morning in family medicine, followed by an afternoon in pediatrics, for instance.
Their experiences include hospitals and clinics, large and small, urban and rural, working with diverse patient populations. The students train part of the time in rural or medically underserved settings, forming ties with these communities.
Patients participate in their training, too, and the students have the opportunity to see the same patients at different stages in their disease. They might, for instance, see a man who just had a heart attack as a hospital inpatient, then see him in the clinician’s office after his discharge, and again months later to see how his disease is being managed.
“We get long-term exposure to what patients go through and to different specialties and primary care sites over a good span of months,” said David Choi, a 2016 graduate of WSU Vancouver and a member of WSU’s inaugural medical school class. “Week by week it varies. Last week I had a mix of outpatient pediatrics, worked in a cancer center for a little while and also in the operating room with plastic surgery. I’m getting experience in learning about the area as well as working with patients—what it’s like for them day by day—and also with preceptors over a long period of time.”
“We do something very different from almost every other medical school,” said Dr. Kevin Murray, associate dean of medical education for the Vancouver campus. “We train 100% of our students in the LIC. Lots of schools have a shorter version for a subset of students, so it’s not like this is some big experiment. But it is very unusual for all students to do their entire third year in an LIC.
“We’re not just a new medical school,” he added. “We’re trying to be pretty innovative to improve the education. We designed our program to make it possible for community providers to have a meaningful role without a lot of paperwork, and to embed students in these communities, so when they’re done, they will know the community and be known.”
WSU’s medical school was founded in 2015 to expand medical education and health care access throughout Washington. It was created in part to address a growing shortage of physicians in rural areas. The school seeks students with ties to Washington state and introduces them to underserved communities in the first year. While students train mostly in classrooms in Spokane during their first two years, they spend three weeks over each of those years on one of four clinical campuses (Vancouver, Spokane, Tri-Cities and Everett) and are introduced to medical clinics in those areas.
They also meet local physicians and community agencies and stay with volunteer host families. Even the host families get a taste of medical education, gathering for dinner and a speaker once a week.
Renny Christopher, vice chancellor for academic affairs at WSU Vancouver, hosted a medical student for six separate weeks over the past two years. As a WSU employee, Christopher would have supported the medical school anyway, but hosting provided an unexpected outcome: Because she got to know the student who stayed with her and others who are her friends, Christopher now feels an investment in these students’ success. They are people she cares for who are pursuing a cause she believes in.
“We give them an opportunity to get more involved in the community as of the first year,” said another host, Catherine Pence of Vancouver. “They want to have an ally, and that’s what we provide.”
WSU also sought clinical partners and preceptors to be part of WSU medical students’ education. (See sidebar for a list of Vancouver-area partners.) “We’re a community medical school,” Murray said. “We don’t have our own hospitals and clinics. We are totally dependent on local hospitals and organizations giving us access.”
One enthusiastic preceptor as well as a host is plastic surgeon Dr. Richard Green. “I see my role as passing along tips, tricks and techniques to help students gain confidence and enjoy their work,” he said.
ESFCOM’s fourth year is a work in progress, Murray said, but will include offering students more experience in clinical practice, as well as an emergency room clerkship and a “sub-internship” in the residency area of their choice. Even if they choose to specialize, he said, they will be well prepared in the primary disciplines.
Another unique facet of the WSU’s medical school is the use of Entrustable Professional Activities, called EPAs. These discreet elements that need to be mastered before a person can be licensed and certified are typically part of a residency, but WSU has established 13 EPAs for students, such as performing a patient history and physical, recommending and interpreting diagnostic tests, and collaborating on interprofessional teams.
“Medicine is a lot more technical today, more safety conscious; there are more legal issues, more specialties,” Murray said. “So we said, if that’s where residencies have gone, let’s use that concept for our medical students, but defined at the medical student level.”
Choi was surprised and delighted by the diversity of his class. “Most aren’t traditional students in any sense,” he said. “That’s an outstanding thing for my own learning.”
Choi himself is a nontraditional student. He hadn’t expected to go to medical school because he didn’t think he could even afford college. But he got a College Bound Scholarship to WSU Vancouver, earned a biology degree and now plans to specialize in psychiatry.
Michelle Hedeen is another example. A 2011 graduate of WSU Pullman, she spent a few years working and volunteering in different health positions. “I knew how much of a commitment it was to go to medical school,” Hedeen said. “I wanted to make sure I knew the options. I looked into nursing and paramedic work, and I knew I’d enjoy it, but it wouldn’t be enough. I always wanted to feel there wasn’t a ceiling as to how far I could go in medicine.”
She values her class’s noncompetitive environment and camaraderie, adding, “There are people who’ve had careers in physical therapy, in nursing, military backgrounds—we just bring all kinds of experiences together that I think is really helpful.”
Hedeen’s long-term goal is family medicine somewhere in the Pacific Northwest, preferably in a rural area or small town. She says the ESFCOM philosophy of preparing physicians for underserved communities fits her exactly. “It’s exactly why I wanted to go into medicine, to help people who really need help and to stay local,” she said.
Broad clinical experience
This year, students are picking up clinical skills, such as taking patient histories and writing in charts. “They’re progressively expected to act more and more like physicians,” Murray said. Of course, there are limits to what students may do, and their preceptor is there for more complex procedures.
Dr. Jon Hartinger, a family medicine physician at Providence Medical Group in Camas, Wash., is a preceptor and also one of three site directors for the Vancouver clinical campus. As a preceptor, he mentors a student in his practice; as a site director, he meets with students individually every month to provide feedback and answer questions.
“I was excited to get involved,” said Hartinger, a 2002 graduate of WSU Vancouver who earned his doctorate in osteopathic medicine at Western University of Health Sciences in Pomona, Calif. He appreciates the enthusiasm and work ethic of WSU’s medical students. “They’re all eager to learn,” he said.
He also appreciates their flexibility. “Since it’s the first year, there are some expected hurdles in setting up preceptors and coordinating rotation schedules,” Hartinger said, but “they’re able to roll with the punches.”
Hartinger expects the community philosophy to result in well-rounded graduates who will possess the breadth of medical knowledge that will make them especially valuable in communities where physicians are few and far between. “This approach encourages that,” he said. “I’m excited to see it progress.”
Not one person has dropped out of the ESFCOM’s first class of 60—a fact of which Murray is especially proud. There are also 60 students in the second class, and 80 this fall. The number of applications has risen every year.
“We’re trying to be different in a lot of ways that we think matter,” Murray said. “Our admissions process is different. We’re trying to get people into medical school who come from underserved communities themselves. Our desire to be a medical school that graduates more people to return to our state and make a difference with underserved populations has everything to do with having the four campuses and trying to get the same students experiences at those campuses all four years.”
ESFCOM’s clinical curriculum is all about relationships. Relationships over time with preceptors and patients encourage students to develop their skills, embrace which specialties in medicine best inspire them, and connect them in the communities they serve. In turn, this allows students to be trained to serve all of Washington state. ■
The Elson S. Floyd College of Medicine is named for WSU’s late president, who was instrumental in the establishment of the medical school but died on June 20, 2015, before the school opened. The first class was enrolled in August 2017. The college has campuses in Spokane, where first- and second-year students spend most of their first two years, and in Everett, Tri-Cities and Vancouver, where cohorts of medical students train in their third and fourth years.