Progress Notes: One Year in the Future of Medicine
Abraham M. Nussbaum
Johns Hopkins University Press, 2024
It was in 1896, not long after his arrival at the new Johns Hopkins School of Medicine, that Sir William Osler introduced the modern clinical clerkship. Until then, clinical instruction often occurred in amphitheaters in which students might outnumber patients by 20 or even 100 to 1. Believing that active, intimate work with patients was necessary to master clinical medicine, Osler imposed a new system in which students rotated among the hospital wards, participating in patient care under the supervision of more experienced physicians.1 When Abraham Flexner catalogued the state of American medical education in 1910, he held up the Johns Hopkins School of Medicine as the ideal for other schools to emulate,2 thus ensuring the primacy of the rotating block clerkship model for the next century.
In Progress Notes: One Year in the Future of Medicine, Dr. Abraham Nussbaum, a psychiatrist and Chief Education Officer at Denver Health, describes an alternative to the Oslerian clerkship model: the longitudinal integrated clerkship (LIC). Rather than beginning (and ending) their specialty training every 4-8 weeks, LIC students selectpatients, then follow them wherever they receive care. A laboring mother met on the obstetric ward might then be followed through subsequent visits to the emergency department or her psychiatrist. As Nussbaum explains, LICs aim to overcome the erosion in altruism that occurs over the clinical (“cynical”) years of medical education by teaching students not only from “the textbook of the body,” but also the “textbook of the community.”
The setting for Progress Notes is the University of Colorado. The protagonists are 7 third-year medical students embarking upon their LIC. The students’ backgrounds are varied—from native Coloradans to international students, from former schoolteachers to former soccer players. So too are their aspirations: the LIC cohort includes both aspiring internists and ophthalmologists. Yet in Nussbaum's hands, the characterization of the LIC participants is uniformly sympathetic, almost always engaging, and occasionally truly captivating. The author casts a discerning eye on the students, through their small wins and big losses, and conveys the sense of becoming nearly as well as the best first-person accounts in the ‘becoming a physician’ genre. The prose is lively and vivid. For readers who have not personally experienced the everyday drama of clinical clerkships, Nussbaum provides a bird's eye view of what it takes to become a doctor. For readers who have, the authenticity and universality of the students’ experiences will resonate.
What is less clear is whether the LIC truly represents the future of medical education. It does at the University of Colorado, where the pilot described in Progress Notes has since been expanded to include all third-year students.3 Yet the LIC concept is not new: some schools have utilized such curricula for over 30 years.4 Despite favorable educational outcomes,5,6 fewer than 1 in 3 MD-granting medical schools even offer LICs, and growth in LICs appeared to have plateaued when last assessed in 2016.7 Readers of Progress Notes will have no difficulty identifying some of the barriers to scalability and sustainability noted in the literature8,9 (eg, both tireless, compassionate preceptors and community-focused students and settings are scarce resources in modern medical education). Yet after completing Progress Notes, readers might also wonder whether the LIC model is really so different than the ideal model for clerkship education that Osler envisioned.
Nussbaum conveys that, more than anything else, LICs are intended to promote a patient-centered approach to care. From that standpoint, the LIC seems perfectly aligned with Osler's “natural method of teaching,” in which “the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.”10