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As the number of people living with chronic illness in the United States rises, it is imperative that medical school prepare physicians who are capable of caring for these patients. This article outlines a creative educational intervention to teach third- and fourth-year medical students about caring for chronically ill people. All students at Weill Medical College, Cornell University, make home visits to homebound older adults with an interdisciplinary team as part of a mandatory Primary Care Clerkship. Under their guidance, students observe the myriad challenges facing homebound older adults. Afterward, students create a project, using original or found art, to express their reactions and thoughts. Students present projects to peers in a small group, with multidisciplinary faculty mentors framing the discussion. To evaluate the intervention, students responded to a nine-item questionnaire and a series of open-ended questions. Quantitative and qualitative analyses show consistently strong positive responses to the experience. Most students (95.0%) felt that they learned about the complexities of chronic illness care from their home visits. The opportunity to express reactions through a creative project received positive responses with 97.0% of students responding favorably. Ninety-seven percent felt that the discussions with colleagues and faculty increased knowledge of chronic illness care. Nearly all (97.0%) felt they had a better understanding of team and that attitudes toward the chronically ill were positively affected. The coupling of the creative arts with home visits is an effective tool for teaching about chronic illness and may be a useful model for medical schools interested in expanding their chronic illness curriculum.
More than 125 million Americans have at least one chronic illness,1 and most older adults live with multiple chronic diseases.2 This trend is projected to grow exponentially in the coming decades and will impel physicians and other health professionals to have the knowledge and skills to care effectively for this growing population of patients.3 The traditional focus on diagnosis and treatment of acutely ill patients often inadequately prepares future physicians to address the complex chronic health problems of older adults living in the community.4 As Benbassat so aptly states, “Models of care that focus only on the biomedical aspects of disease may erode physicians' humanistic attitudes; awareness of social, cultural and environmental determinants of health; and ability to discriminate between technically possible and morally permissible interventions.”5
Medical trainees need not only more exposure to chronically ill people,6 but also more opportunities to reflect on and process their reactions to caring for such patients under the guidance of confident and compassionate faculty. Doctors and nurses are confronted with intense questions about the meaning of life and are exposed to human tragedies and comic absurdities, sometimes simultaneously.7 A forum to explore and share these experiences can be a welcome group-learning exercise that leads to insights that move students closer to becoming caring and competent physicians. The creative arts can be a vehicle to help conceptualize the lives of patients and tackle complex human experiences with an immediacy and range of responses often lacking in medicine.7
As part of the Donald W. Reynolds Grant to enhance the Weill Cornell Medical College (WCMC) curriculum in geriatric medicine, the Chronic Illness Care in the Home Setting Program (CIC-HSP) was developed and implemented as part of a mandatory 6-week third- or fourth-year Primary Care Clerkship. The objectives of the module for students are to recognize the importance of chronic illness care, in particular, the effect of psychosocial factors on health and quality of life; appreciate the collaboration of an interdisciplinary team in helping older patients manage illness; express thoughts and emotions experienced during house call visits through a creative project; and allow exposure to a broad range of student experiences through shared group discussion with geriatrics faculty.
The house call is an ideal model for teaching chronic illness care. Seeing patients in their own environment can more clearly illustrate the interplay of multiple factors and allow for a more-interactive and stimulating learning experience.8 In a previous survey of 50 WCMC medical students and recent graduates regarding their home visit experience, the authors found that the house call exposure improved students' attitudes toward caring for chronically ill people and their understanding of the medical and psychosocial aspects of chronic illness care.9 This current study expands upon and corroborates that research, with an added focus on how creative projects, group reflection, and faculty guidance enrich the understanding of chronic illness.
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The Division of Geriatrics created this educational program as part of its effort to expand geriatrics within the 4-year curriculum at WCMC. Faculty were recruited from several disciplines to design and implement the material.
At the start of each rotation in the third-year Primary Care clerkship, students receive an introductory packet with course objectives and instructions about the home visit session and the class presentations, an observation worksheet to help them focus on salient themes related to chronic illness and home care (e.g., why patient is homebound, how functional or mobility impairments affect patient's access to health care), a checklist of common themes relating to chronic illness care, and selected readings.
All third-year students then engage in a three-part educational intervention:
Home Visits. Each student meets with the house call team and is oriented to each of their roles. During the half-day of visits, the student is encouraged to interact with the older patient and observe patient interactions with home attendants, family, and other community participants. Afterward, the interdisciplinary team debriefs the student and encourages the student to raise any questions or concerns about the visit(s).
Creative Projects and Presentations. Students channel their individual thoughts and emotions sparked by the home visit into a creative project (original or found art) such as a poem, musical composition, short story, collage, photograph, painting, or narrative.
Interdisciplinary Discussion. During two 1.5-hour sessions, interdisciplinary faculty facilitate discussions about the chronic illness themes with the presenters and their peers. Students submit their projects to the faculty, along with a brief written description of how they relate to their home visit experience(s).
At the end of the second seminar, students complete an evaluation rating the home visit and seminar experience using a nine-item questionnaire with a 4-point Likert scale, along with open-ended questions about what they thought was worthwhile, what they would change, and additional comments, and identifying chronic illness themes discussed during the seminars. Over a 2-year period, 82.8% (164) of the 198 students enrolled in the Primary Care Clerkship submitted program evaluations. This study analyzes these data. The study was exempted from institutional review board approval.
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Findings presented in Table 1 corroborate those of the authors' previous study showing that most students reported having learned about the complexities of chronic illness care from their home visit (95.0%).9 Nearly all students (97.0%) believed the home visit increased their understanding of how the interdisciplinary team cares for chronically ill patients. A majority (98.5%) thought that the interdisciplinary geriatrics faculty enabled them to recognize the interplay of patients' psychosocial and medical problems. Most (93.8%) stated that they highly valued the informal field discussions with faculty after the home visit. Overall, 97.3% felt that the module positively affected their attitudes toward the care of chronically ill older adults, as reflected in their open-ended responses:
Table 1. Composite Average of Quantitative Results for Third- and Fourth-Year Students (N=164)
|Strongly Agree||Agree||Disagree||Strongly Disagree||Not Applicable|
|1. The home visit increased my knowledge about chronic illness care.||71.7||26.4||0.8|| ||1.1|
|2. The home visit increased my understanding of how the interdisciplinary team helps patients with chronic illness.||78.5||18.5||2.3|| ||0.7|
|3. The Observation Worksheet helped me prioritize the more salient elements of care of the chronically ill patient in the home.||23.8||51.5||12.5||2.0||10.2|
|4. The discussion(s) about the home visits with my preceptor was (were) valuable.||68.4||25.4||2.8|| ||3.4|
|5. The readings increased my knowledge of chronic illness and chronic illness care.||23.4||54.4||8.7||1.0||12.5|
|6. My class presentation gave me the opportunity to reflect on chronic illness and chronic illness care in the home.||67.7||29.3||2.4||0.6|| |
|7. Listening to other presentations increased my knowledge about the complexities of chronic illness care in the older adult.||71.0||23.5||4.0||1.0|| |
|8. The geriatric faculty helped me recognize the psychosocial implications of medical problems (and vice versa) in patients lives.||80.0||18.5||1.5|| || |
|9. The overall experience positively affected my attitude toward care of the chronically ill older patient.||82.3||15.0||2.1|| ||0.6|
I really thought the experience was great, integrating and focusing on the humanistic aspect of disease and aging. I know it comes up in the discussions over and over, but seeing the older patient as more than a disease was something this project accomplished.
The entire experience provided a deeper understanding of geriatric care and our own emotional response to aging.
Students seemed to appreciate the opportunity to create and share their own responses to their house call exposure (97.0%) and valued their peers' creative efforts and depth of insight during the presentation seminars 94.5%). Table 2 reflects the breadth of original and found artistic forms that students used in creating their projects. These original or found artistic representations of themes and experiences were wide ranging: poems capturing a patient's mood; narratives depicting a student's trepidation, amazement, or sadness; original short films or radio broadcasts depicting a patient's earlier life or current disabilities; photo montages of home interiors symbolizing isolation; a timeline noting major events that had occurred during the patient's lifetime; and even food preparation invoked by smells experienced in the home.
Table 2. Distribution of Art Forms Used in Creative Projects N=164
|Art (painting or sketch)||4.0||6.6|
|Film, video, or audio||3.1||2.0|
Of the total projects, 63.9% were original; only 36.1% of the students relied on the “found” works of other artists. Of the 14 identified categories, 34.8% were poems, with found and original almost equally represented. Original nonfiction in the form of narratives (students' personal reflections of their home visit experiences) was the next-most-used medium (16.7%). In total, literary arts accounted for 59% of the total projects (23.5% found, 35.4% original). Visual arts accounted for 28% of the projects (7.9% found, 19.7% original), with paintings and sketches making up 10.6%, photography 6.6%, and film and collage, 10.4%. Crafts (2.0%) included such activities as jewelry making, quilting, and knitting. Less well-defined categories were grouped under “other” (1.7%), such as kaleidoscopes, architectural models, and timelines. Some students' projects overlapped two artistic mediums but were counted in only one category (e.g., original photo montage set to found music).
Students indicated that each of the 24 chronic illness themes listed on the checklist had been discussed during the presentation seminars (Table 3). More than half of the students noted each theme, with caregiver stress (80.0%), role of social history (82.0%), and assessing social supports (88.6%) being the most frequently recognized.
Table 3. Chronic Illness Care Themes: Composite Average (N=164)
|Types of chronic illnesses||65.7|
|Patient's search for meaning||67.2|
|Community resource needs||68.2|
|Safety in home environment||61.9|
|Mental health issues||82.2|
|Effect of chronic illness on family||82.5|
|Importance of team||77.0|
|Patient coping styles||76.7|
|Grief and loss issues||75.8|
|Lack of cure or permanence||61.1|
|Elder abuse and neglect||45.2|
|Current life stressors||59.4|
|Variableness of team composition||43.1|
|Quality of life||79.4|
|Reasons for “homeboundedness”||85.6|
|Right to self-determination||52.9|
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In addition to efforts to ensure that students acquire knowledge about the salient themes in chronic illness care, this curriculum emphasizes the experiential element of the students' visits, rather than focusing on classic medical case presentations.
Students' understanding of and insight into chronic illness themes were highlighted and enhanced through creating and discussing their projects over the two seminars. Because no single patient can expose students to all of the complex issues involved in chronic illness care, the faculty attempted to meld individual patient experiences into a full, well-rounded mosaic of chronic illness care. No one individual's experience could be as robust as the collection of stories and reactions of the group.
It is noteworthy how many chronic illness care themes students perceived to have been discussed during presentation seminars, but perhaps more striking were the different approaches used by students to discuss these themes. For example, one student's presentation triggered a rich, moving discussion that touched on several themes germane to chronic illness care. He selected a passage from My Own Country, in which Abraham Verghese describes his physical examination of Luther, a patient dying from acquired immunodeficiency syndrome:
As I pick up my tools, one by one, I realize that all I have to offer Luther is the ritual of the examination, this dance of a Western shaman … whatever doctors do when medicine no longer “works,” it doesn't seem to be rational or scientific or orderly… And yet, on another level, the examiner's attention to his dying patient suggests a different, more appropriate ordering. The life-saving crisis moves to the background and the timeless rituals of caring and compassion move to the fore. We begin to focus less on the future and more on the present, less on outcomes and more on process.10
Many students sympathized with the insecurities that physicians have, at times feeling as if they are versions of a shaman. Others appreciated the feelings of inadequacy physicians may have as they face dying patients. The idea of illness versus disease, caring versus cure, and the concept of a “good death” all ensued from this single presentation.
Another student chose to make a second visit to a patient with advanced dementia on a quest to understand this patient as a complete person. The student then wrote a personal (but unsent) letter to her patient to explore the powerful feelings these visits evoked. She wrote:
… I felt like I needed to forage for more pieces of you. … I surprised myself when I found myself requesting to go back and see you again on my own.… I was moved to return because the last visit seemed to discombobulate me, so much so that I left with the impression that you almost weren't a person anymore. I saw your wasting, smelled your sickness, felt your paper-thin skin and heard your problem list. But I certainly didn't see you, did I?
This student clearly struggled with her initial reactions to this elderly patient with dementia and after her second visit appreciated that she was able to see the person behind the dementia after speaking at length with her home attendant and learning about her life. The class discussion touched on how to relate to patients with dementia, what and who determines quality of life, appreciating the importance of the life narrative in humanizing care, and the vital role of caregivers.
After visiting a feisty homebound older woman with chronic obstructive pulmonary disease and lifelong alcohol abuse, another student wrote and performed on his guitar an insightful song, You Can't Take the Fight Out of Me. Some of the lyrics follow:
So at last the conversation turns
To the point we argue most
You've tried to slow my drinking
But you've never understood
That I've traveled ‘round the world
And a nip can set me free
To escape to distant places in my memory
This student's project engendered a discussion about patients' rights to self-determination, alcohol abuse, identifying depression, and how to partner with patients to make behavioral changes.
Students put intense, passionate effort and time into developing and presenting their projects. It is this active learning aspect of the curriculum that is critical to its success.11 As Branch et al. state, “Active learning methods engage learners in doing, discussing, and reflecting … [and] more effectively promote humanistic skills, attitudes, and values.”12 Anecdotally, it has been observed that this enthusiasm has clearly “snowballed” since the inception of the project, with excitement being passed down from one class to the next.
Students often mentioned that this is the only opportunity during their medical school training during which they can incorporate their talents, insights, and emotions into truthful revelation.
Visiting patients in their home was most valuable because of the creative presentation. It allowed us the time to focus on our experience, share, and discuss ideas. One of the best experiences yet in medical school.
The experience as a whole was eye-opening and thought-provoking. I especially appreciated the opportunity to discuss with classmates such an emotional and personal topic, something we do far too little in med school.
An unanticipated outcome of the program was the fascination of medical students with their colleagues' experiences and the associated window into their thoughts, emotions, and reflections. The secret to each group's engagement was a comfortable learning environment that allowed for an openness of expression and a shared vulnerability among colleagues. Student presentations and class discussions revealed the many issues involved in this clinical work, often leading to profound discoveries.12
Students' comments support how the presentation seminar to faculty created an environment safe for self-reflection and revelation. In many ways, this has become a team-teaching experience, a bidirectional student–preceptor collaborative learning effort that emphasizes a shared humanity. The faculty encourage student self-expression, respond empathetically to displays of emotional vulnerability (e.g., insecurity, sadness, frustration), and model respect for diversity. Additionally, the faculty's prior clinical experiences with the patients often provide relevant insights about them that the students are seeing for the first time. Faculty reinforce a humanistic model of care by successfully demonstrating how they value their long-term relationships with patients and the deep sense of fulfillment they gain from caring for them longitudinally.
In turn, this open venue for reflection and expression is in many ways as valuable for the faculty as it is for the students. Facilitating the presentation seminars often gives faculty new insights into their own relationships with the patients being discussed. The wide range of student creativity, openness to reflection, and insight also engages and energizes them. They have an opportunity to revisit the reasons they chose this work and, in doing so, reaffirm their commitment to it.
For the faculty, observing a medical student who really “gets it” is truly gratifying. The poem “On His Life Bed,” composed by a student after visiting an actively dying patient, reflects the young trainee's ability to capture a poignant and deeply personal moment in the patient's life. This excerpt demonstrates that he clearly was able to appreciate and integrate the concept of “care, not cure.”
… The wife asks: “how much longer, do you think?”
The doctor's self-assured response: “not much longer… days”
“The white blood cell count is now also high”
“We could conceivably give him antibiotics, but…”
“I understand, doctor. I really understand. Let's let him be.”
And so he lay there, all 102 years of him, in his own home, surrounded by
His art collection, with his masterpiece of 30 years holding his hand
And whispering “I'm right here, I'm right here.”
“Bye, Bye” interrupts his doctor, leaning in to catch his eyes for the last
His blood revisits his face,
His lungs remember to blow
We could all only hope to be so lucky
This was a seminal event for the medical student, the faculty preceptor, and the patient's wife. Taking advantage of such moments can be an effective way for learners to absorb lessons that will often stay with them for a lifetime.12 By titling the poem “On His Life Bed” and describing this poignant scene, the student captures the realization that there is opportunity for life and meaning until the last breath is taken.
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This educational program is a useful and effective tool to teach about chronic illness care that could easily be reproduced at other medical schools. The first step is buy-in from the course director. Although this particular endeavor uses home visits as the backdrop to teach chronic illness, the setting could just as easily be a nursing home, rehabilitation facility, or even a geriatrics practice. Arguably, if the purpose is to teach chronic illness, even some pediatrics practices would be appropriate. One hurdle schools must overcome is finding faculty time for the clinical precepting and seminar facilitating. Ideally, an administrative assistant would schedule the student visits and seminars.
Although it has been demonstrated that the house call by itself has a positive effect on attitudes and knowledge about chronic illness care,9 the researchers' study did not include the creative project and seminars in their study. Future research should examine the longitudinal effect of the entire CIC-HSP program on medical trainees' attitudes, knowledge, and skills in providing chronic illness care.
More effort should be placed into introducing students to chronic illness care in other settings and to igniting students' engagement in a deep and abiding manner throughout their medical school training.
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We would like to thank Deirdre Mole, GNP, a beloved mentor and teacher, for her years of educating students, residents, and fellows about the care of homebound older adults.
The authors would also like to acknowledge Arun Rao and Dr. Taryn Yeon Lee for their dedication, caring and ongoing commitment to teaching and Donna Rosensteil, CSW, and Amy Stern, CSW, for their contributions to the project.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.
This work was supported by the Donald W. Reynolds Foundation, the Charles and Mildred Schnurmacher Foundation, and Cecile and Jerry Shore.
Author Contributions: Veronica LoFaso, Risa Breckman, and Carol Capello: study concept and design, acquisition of subjects and data, analysis and interpretation of data and manuscript preparation. Ronald Adelman: study design, analysis and interpretation of data and manuscript preparation. Byron Demopoulos: study design and concept and acquisition of subjects and data.