Article 11 Rosenthal MS, Lucas GI, Tinney B, et al. Teaching community-based participatory research principles to physicians enrolled in a health services research fellowship. Acad Med. 2009;84:478–484. 12 Horbar JD, Badger GJ, Carpenter JH, et al. Trends in mortality and morbidity for very low birth weight infants, 1991–1999. Pediatrics. 2002;110:143–51. 13 Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202.
14 Vasilevskis EE, Knebel RJ, Wachter RM, Auerbach AD. California hospital leaders’ views of hospitalists: Meeting needs of the present and future. J Hosp Med. 2009;4:528–534. 15 Schmittdiel JA, Grumbach K, Selby JV. System-based participatory research in health care: An approach for sustainable translational research and quality improvement. Ann Fam Med. 2010;8:256–259. 16 Nembhard IM. Learning and improving in quality improvement collaboratives: Which collaborative features do participants value most? Health Serv Res. 2009;44(2 pt 1): 359–378.
17 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381. 18 Williams MV, Coleman E. BOOSTing the hospital discharge. J Hosp Med. 2009;4:2 09–210. 19 Schnipper JL, Roumie CL, Cawthon C, et al. Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study. Circ Cardiovasc Qual Outcomes. 2010;3:212–219.
Teaching and Learning Moments The Fifth White Coat
Bundled in several sweatshirts and a knit hat, Rosa clenched her jaw when she wasn’t speaking. She constantly bounced her legs while her hands busied themselves rubbing the fronts and sides of her thighs. Invisible pains began, and she drew in long breaths, eyes shut. The cool weather made the pain worse; she’d told me this many times. Four white coats marched into the room—the attending, the fellow who took Rosa’s history, the fellow Rosa usually saw, and another medical student. One, two, three, four white coats formed a semicircle around us. In the middle of the room seated in low chairs, Rosa and I bent our necks to look up at the faces of the ivory towers above us. I met Rosa, a longtime patient of my internal medicine preceptor, at the beginning of my third year of medical school. Every month in the small exam room of an urban New England community clinic, we discussed her ulcerative colitis and mysterious leg pains. Eventually she scheduled her visits only on my clinic days. I was able to see her across the academic year because I participated in a longitudinal integrated clerkship (LIC). The program promoted patient-centered learning, and though I didn’t know what that was, I applied because it sounded
420
like the kind of medicine I ultimately wanted to practice. When Rosa had an appointment at a tertiary hospital’s colitis center, she asked if I would accompany her. I agreed— integral to the LIC is following patients across disciplines as well as time. She even asked if I could give her a ride and if we could travel together, but, since I only had a bicycle, I joined her there. A gastrointestinal fellow who Rosa had never met before took an interval history and stepped out. One white coat left. Four white coats returned. In the exam room, the fellow gave a formal presentation. Forty-six yearold female with two-year history of treatment-resistant UC returns. The gastroenterologist told Rosa what he wanted to do next, and the second fellow piped in occasionally. My classmate, the medical student, never spoke. The visit ended when the attending physician told me to relay his plan to Rosa’s primary care doctor. One, two, three, four white coats marched out. A fifth white coat was missing from the lineup—mine. I could have been the fifth white coat, hovering silently above Rosa in that semicircle. Yet, sitting alongside her in the center of the room, I learned with Rosa instead of about Rosa.
I observed care from her perspective; I stayed when the others walked out. This was patient-centered learning. The two of us remained in our seats in the exam room, and, after a long exhale, Rosa turned to me. “So, what’s going to happen?” she asked. I became the Englishto-English interpreter of the medical jargon and listened to her unasked questions. She put on another jacket to shield against the season’s chill and, for the first time, gave me a hug. The layers of her clothes were soft and thick. We’d see each other again at her next appointment. On the way home from the hospital that day, I contemplated how close I had come to being the fifth white coat and how I would someday certainly be that fifth white coat to my unmet patients. Pedaling against the autumn chill, I vowed to always sit with my patients mentally even when standing above them physically, to imagine, at least for a second, the situation from their perspective, and to wear a white coat, not become one. Author’s Note: The name in this essay has been changed to protect the identity of the patient. Sophia K. McKinley Ms. McKinley is a medical student, Harvard Medical School, Boston, Massachusetts; e-mail: [email protected].
Academic Medicine, Vol. 89, No. 3 / March 2014
14 Vasilevskis EE, Knebel RJ, Wachter RM, Auerbach AD. California hospital leaders’ views of hospitalists: Meeting needs of the present and future. J Hosp Med. 2009;4:528–534. 15 Schmittdiel JA, Grumbach K, Selby JV. System-based participatory research in health care: An approach for sustainable translational research and quality improvement. Ann Fam Med. 2010;8:256–259. 16 Nembhard IM. Learning and improving in quality improvement collaboratives: Which collaborative features do participants value most? Health Serv Res. 2009;44(2 pt 1): 359–378.
17 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381. 18 Williams MV, Coleman E. BOOSTing the hospital discharge. J Hosp Med. 2009;4:2 09–210. 19 Schnipper JL, Roumie CL, Cawthon C, et al. Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study. Circ Cardiovasc Qual Outcomes. 2010;3:212–219.
Teaching and Learning Moments The Fifth White Coat
Bundled in several sweatshirts and a knit hat, Rosa clenched her jaw when she wasn’t speaking. She constantly bounced her legs while her hands busied themselves rubbing the fronts and sides of her thighs. Invisible pains began, and she drew in long breaths, eyes shut. The cool weather made the pain worse; she’d told me this many times. Four white coats marched into the room—the attending, the fellow who took Rosa’s history, the fellow Rosa usually saw, and another medical student. One, two, three, four white coats formed a semicircle around us. In the middle of the room seated in low chairs, Rosa and I bent our necks to look up at the faces of the ivory towers above us. I met Rosa, a longtime patient of my internal medicine preceptor, at the beginning of my third year of medical school. Every month in the small exam room of an urban New England community clinic, we discussed her ulcerative colitis and mysterious leg pains. Eventually she scheduled her visits only on my clinic days. I was able to see her across the academic year because I participated in a longitudinal integrated clerkship (LIC). The program promoted patient-centered learning, and though I didn’t know what that was, I applied because it sounded
420
like the kind of medicine I ultimately wanted to practice. When Rosa had an appointment at a tertiary hospital’s colitis center, she asked if I would accompany her. I agreed— integral to the LIC is following patients across disciplines as well as time. She even asked if I could give her a ride and if we could travel together, but, since I only had a bicycle, I joined her there. A gastrointestinal fellow who Rosa had never met before took an interval history and stepped out. One white coat left. Four white coats returned. In the exam room, the fellow gave a formal presentation. Forty-six yearold female with two-year history of treatment-resistant UC returns. The gastroenterologist told Rosa what he wanted to do next, and the second fellow piped in occasionally. My classmate, the medical student, never spoke. The visit ended when the attending physician told me to relay his plan to Rosa’s primary care doctor. One, two, three, four white coats marched out. A fifth white coat was missing from the lineup—mine. I could have been the fifth white coat, hovering silently above Rosa in that semicircle. Yet, sitting alongside her in the center of the room, I learned with Rosa instead of about Rosa.
I observed care from her perspective; I stayed when the others walked out. This was patient-centered learning. The two of us remained in our seats in the exam room, and, after a long exhale, Rosa turned to me. “So, what’s going to happen?” she asked. I became the Englishto-English interpreter of the medical jargon and listened to her unasked questions. She put on another jacket to shield against the season’s chill and, for the first time, gave me a hug. The layers of her clothes were soft and thick. We’d see each other again at her next appointment. On the way home from the hospital that day, I contemplated how close I had come to being the fifth white coat and how I would someday certainly be that fifth white coat to my unmet patients. Pedaling against the autumn chill, I vowed to always sit with my patients mentally even when standing above them physically, to imagine, at least for a second, the situation from their perspective, and to wear a white coat, not become one. Author’s Note: The name in this essay has been changed to protect the identity of the patient. Sophia K. McKinley Ms. McKinley is a medical student, Harvard Medical School, Boston, Massachusetts; e-mail: [email protected].
Academic Medicine, Vol. 89, No. 3 / March 2014
