PISCES: Better Teaching and Care

reprinted from Issue 12, Spring 2011 of Frontiers of Medicine (PDF)

From left: Dr. Karen Hauer, third-year medical student and PISCES participant Jenny Cohen and patient Chris Krajewski discuss Krajewski's medical care and treatment.
photo by Noah Berger


When Chris Krajewski was hospitalized last summer, she met third-year medical student Jenny Cohen, who was on an inpatient rotation. "From the time she introduced herself, I've been really closely in touch with Jenny," says Krajewski. "She's been the most incredible advocate for me, and working with her has made a huge difference in my medical care."

The fifth grade teacher was eventually diagnosed with pulmonary hypertension, a serious condition that makes it difficult for the heart to pump blood through the lungs. In the months since their first meeting, Cohen has participated in most of Krajewski's medical care, assisting during visits to her primary care physician, accompanying her to pulmonology, cardiology and hematology appointments, and touching base by phone or e-mail several times a month.

"Now that I have these different conditions that are pretty serious, they all get parceled out to specialists," says Krajewski. "As a patient, it can feel scattered and disjointed, but having someone who helps you pull it all together is really great." She says that Cohen reads every doctor's note and test result in her chart, and translates the information from "medical-speak" to plain English. "She's also shown a lot of care for me as a person," says Krajewski. "It's really touching, and has an impact on how you feel."

Cohen is part of an innovative educational program called PISCES (Parnassus Integrated Student Clinical Experiences), which provides third-year students the opportunity to follow a cohort of about 80 patients for an entire year. In contrast to traditional block clerkship models, in which students spend four to eight weeks at a time learning about a single specialty, PISCES is an example of a Longitudinal Integrated Clerkship (LIC). Students spend half a day in one of 12 different medical and surgical specialty clinics during a repeating two-week schedule, punctuated throughout the year by six weeks on inpatient rotations or on call. Instead of moving to a new site every month or two, most of the students' clinics are based on the Parnassus campus.

Because the PISCES rotations include one or two unscheduled slots per week, students can also accompany patients like Krajewski to other appointments. By observing multiple specialist physicians and other health professionals, such as dialysis nurses and nutritionists, students gain a deeper understanding of how health care teams can work together to treat complex illnesses. "To gain the perspective of these very highly trained, specialized physicians has been a real gift, which I don't think I would have gotten if I hadn't been in this program," says Cohen.

Now in its fourth year, PISCES has 16 students, and is co-directed by Ann Poncelet, MD, and Maria Wamsley, MD. UCSF has become one of only a handful of schools to pilot the LIC model. In addition to PISCES, there are similar programs based at the San Francisco Veteran Affairs Medical Center, San Francisco General Hospital and UCSF Fresno. This spring, a new LIC based at Kaiser Permanente in Oakland will start, marking a new educational partnership between UCSF and Kaiser. Overall, about half of third-year medical students at UCSF choose to participate in LICs.

Karen Hauer, MD (with student Jenny Cohen)
photo by Noah Berger

Greater Continuity

Dramatic changes in the practice of medicine have contributed to the need for new educational models, says Karen Hauer, MD, director of internal medicine clerkships. "Long ago, students in the traditional block clerkships worked with a one-month continuous team of an attending (supervising faculty physician), some residents and interns, and patients that stayed in the hospital for a week or two," she says. "These days, all that is on fast forward."

Attendings have shorter stints in the hospital, residents turn over more frequently because their workweeks are now capped at 80 hours, and patients in the hospital tend to be sicker, while their hospital stays are shorter. Also, the majority of today's health care occurs in the outpatient setting, rather than the hospital. "When it comes time for students to be evaluated, they feel like everyone saw them in a snapshot, but nobody really knows how they are developing over time," says Hauer.

To address this shortcoming, PISCES students work closely with seven faculty preceptors, gradually taking on more clinical duties as their knowledge develops during the year. "In my own students, I see a very nice development of understanding how to work within the system to bring information from one doctor to another, and to the patient," says Hauer, who serves as Cohen's internal medicine preceptor. "A big reward for these students comes when their patients start to call upon them and appreciate them. They feel more like doctors, and like they're really having an impact."

"My attendings have done a stellar job of gauging my level, and slowly ramping me up," says Cohen. For example, initially her family medicine preceptor observed as Cohen took a patient's history, and would always stay for the full discussion at the end of the appoint- ment. "Now we've gotten to a point where she really lets me fly," says Cohen, who gathers all the information from patients, develops a list of issues and how they might be addressed, and who stays after her preceptor leaves to field any extra questions from the patient.

Cohen is also there for patients when setbacks arise. For example, a paging system notified Cohen when Krajewski was hospitalized during the holidays, and Cohen was able to check in on her by telephone. "Oftentimes, patients don't want a medical student," says Cohen. "We add time to their visit, we're a clumsy set of hands they don't want to deal with. But sometimes we can provide a service, like picking up the phone at nine on a Sunday night to hear that you're out of the hospital, and helping to coordinate follow-up care."

Better Patient Understanding

Krajewski says she has benefited from the relationship as well. "Jenny is the person who is most on top of what's going on with my health," says Krajewski. "She's really smart, has a great memory, and has done research on questions that I have, helping me to be educated and informed. I think Jenny will be really exceptional, and I hope I can have her as my doctor when she finishes medical school."

Getting to know patients over the course of a year also brings depth to the relationship with patients. When accompanying patients to specialty appointments, Cohen has spent an hour or more in the waiting room with them, and learns about their jobs, struggles with insurance companies, and the difficulties of raising children while struggling with medical issues. "We often have the luxury of time to let things unfold, and to let these relationships develop," she says. "Stories often take more than one or two office visits to start unraveling."

The program is not without its challenges. "I constantly feel guilty if I don't go to a patient's appointment in order to study or chart notes," says Cohen. "With flexibility comes a lot of difficult choices. We all have to triage our time and use it wisely."

Yet the payoffs are substantial. "The amount of consistent, incredible teaching I get from my attendings has imbued my third year experience with such positivity, and made it a very meaningful and enriching experience, instead of a depleting one," she says. "I feel like one of the luckiest students out there to be able to work with these attendings and patients."