Photos by Kelsey Daugherty, Ginny Sturgill, Ellen Johnson and Bryan Hester
When one of Elizabeth Junkin’s patients, a man in his 50s, came to a rural family-medicine clinic with abdominal pain, she suspected appendicitis. She recommended a CT scan that confirmed her diagnosis, then drove to the local hospital in Carrollton, Ala., to check on the man. No surgeons were available, so the emergency surgery he needed could not be performed there. With all ambulances at least a 2-hour drive away, Junkin helped arrange a helicopter flight to DCH Regional Medical Center in Tuscaloosa. She met the man there, assisted with his surgery and followed up with him the next day.
Junkin did all this not as a doctor, but as a third-year medical student at the University of Alabama School of Medicine’s Tuscaloosa Regional Campus. She’s part of an innovative program called the Tuscaloosa Longitudinal Community Curriculum, or TLC², created by
The University of Alabama College of Community Health Sciences, where the Tuscaloosa Regional Campus is housed. Instead of a rotation schedule that requires spending four to eight weeks in each of seven specialty areas, TLC² students are based with primary-care physicians and cover the various specialties throughout the year by following individual patients as they visit specialists and navigate the health-care system.
“Being able to see a patient from diagnosis to surgery is a very rare opportunity for a medical student, and I’m so thankful I was able to participate in this,” Junkin says of her work with the appendicitis patient. “This experience allowed me to see challenges for rural hospitals as well as what a patient who lives in a rural area has to go through sometimes.”
Dr. Cathy Skinner, a physician at University Medical Center-Northport, which is operated by CCHS, and Carrollton Primary Care and a UA assistant professor of family medicine, says TLC² creates a win-win-win situation for students, physicians and patients. A main goal of the program, which launched in 2014, is to help students gain an understanding of the social and cultural factors affecting patients’ health.
“In a traditional clerkship, students see the diabetic patient as the diabetic in room three,” says Brook Hubner, director of medical student affairs at CCHS. “In a longitudinal clerkship, we hope that the students will see the diabetic patient as Mrs. Smith with diabetes and learn where she lives, where she works, the amount of fresh food available in her neighborhood, whether she has safe or easily accessible places to exercise, her education level and health literacy, etc.”
In addition to getting to know individual patients, TLC² students become familiar with entire communities, and each student completes a service project tailored to the area where he or she works.
While TLC² is the only longitudinal integrated clerkship in Alabama, the program is modeled after others, including those at Harvard Medical School and the University of Minnesota. Research has shown students in longitudinal clerkships perform as well or better on standardized knowledge and skills tests compared to students in traditional third-year programs, yet form deeper connections with patients and attain higher levels of patient-centered attitudes.
TLC² students each develop a panel of approximately 25 patients, with their physician mentors recommending patients with chronic and other conditions requiring them to see specialists as well as visit a primary doctor regularly. Students see these patients at primary-care office visits, accompany them to specialists’ appointments and help treat them in the hospital.
“A patient gets a full-circle overview with the same medical provider by his or her side every step of the way,” says Dr. Verquita Scott-Conley, who participates in the program as a pediatrician with the Alabama Multi-Specialty Group in Tuscaloosa.
Skinner says this continuity of care leads many patients to identify with a TLC² student as their “doctor,” and several of her pregnant patients have asked that TLC² students deliver their babies. “Traditional students just do not have the opportunity to develop this long-term relationship with patients,” Skinner says.
TLC² students also can spend more time than physicians listening to patients, who often grow comfortable opening up to them. “Many patients truly appreciate a listening ear,” Skinner says. “This helps me and helps my practice’s efficiency as well.”
Building relationships with patients
In some cases, this extra attention reveals undiagnosed conditions.
Student Danielle Fincher cared for a Spanish-speaking woman during the latter part of her high-risk, sixth pregnancy, and saw her in the hospital when the baby was born. After the woman noted some odd symptoms during a follow-up visit, Fincher, who speaks some Spanish, spent an hour and a half talking with her, eventually realizing the woman suffered from post-partum depression. The way the woman described her feelings was different than expected because talking about post-partum depression wasn’t culturally acceptable for her, Fincher says.
“I doubt she would have been diagnosed [in a typical setting] with the language and cultural barriers and time constraints,” Fincher says. “Or she might not have felt comfortable bringing it up with someone else.”
Junkin says patients she followed frequently commented that it was good to see a familiar face, especially in the hospital. TLC² students also can serve as facilitators when patients see specialists.
“For example, I followed one of my patients with poorly controlled blood pressure to see the nephrologist,” Junkin says. “In the middle of the patient telling his story to the nephrologist, he stops and says: ‘Elizabeth knows the story better than I do… she could tell you better than me.’” Junkin told the nephrologist about different medicines she and the primary doctor had tried and gave a thorough history of their approach.
Working with the same patients over a longer period of time gives students an opportunity to see the impact of their actions and to make connections between patients’ health and other factors in their lives. “We get to see the medical and social sides – what works and what doesn’t,” Fincher says. “We see that when the social aspects of a person’s life improve, health improves.
Fincher helped a patient who was having trouble buying food sign up for the Women, Infants and Children nutrition program and suggested changing prescriptions for medications patients couldn’t afford to similar ones they could get for free or for $4 at Walmart or Publix.
While working in a west or central Alabama town or city, each TLC² student conducts an assessment of the community’s health needs and develops a service project in response to one of those needs.
Student Katherine Rainey, who says she started following friends with a video camera in seventh grade rather than scrapbooking, is interested in the role of film in health education and was able to integrate her hobby into her community project.
The physicians at the Alabama Multi-Specialty Group, where Rainey was based, wanted to make a video for their patients. She and the doctors decided together to focus on childhood obesity and health snacking.
Rainey created a 6-minute video aimed at parents that includes definitions of overweight and obesity, an explanation of the height and weight chart pediatricians use and several tips for providing healthy snacks kids will eat. She says her favorite part of the project was teaching a healthy-snacking lesson to a class of second graders at Southview Elementary School in Tuscaloosa, then filming them enjoying some samples.
Rainey gave parents a survey before and after they watched the video and was surprised by a pervasive lack of recognition of childhood weight problems. Most parents of overweight or obese children don’t think their child is either of those things, she says. The survey also asked if childhood obesity is a problem in the community. After watching the video, more parents agreed it was.
“Kay’s video is helpful in a fun and informative way,” says Scott-Conley, the pediatrician at Alabama Multi-Specialty Group. “It addresses a topic that I all too often have to discuss during many of my patients’ office visits.”
Fincher was inspired to start her community project after hearing stories of negative patient experiences in emergency rooms after sexual assault. She learned Tuscaloosa and its sister city, Northport, don’t have a SANE (Sexual Assault Nurse Examiner) program, which would provide trained nurses to conduct physical exams. A couple of advocacy programs furnish volunteers to go to the ER with victims, but she says medical staff members often aren’t familiar with them and won’t let them accompany patients.
Fincher also found a lack of data related to sexual assault. For her community project, she’s creating baseline data by reviewing patient charts, looking at the treatment people received after sexual assault and comparing it to Centers for Disease Control guidelines.
“I’m particularly excited about it because of the timing,” she says. “There might be more of a receptive audience now because sexual assault on college campuses is such a hot topic and there seems to be so much momentum.”
Junkin says her project stemmed from a need for a diabetes-education program in Dr. Julia Boothe’s clinic, Pickens County Primary Care. Junkin researched diabetes-education programs, the needs of clinic patients and resources available to the clinic. She then organized the information and provided it to Boothe as a guide for picking the best program curriculum and format for her practice.
Medical students in the TLC² program work full time in doctors’ offices and hospitals and also attend class at UA. Through the Leadership in Community and Population Medicine course, led by Dr. Lea Yerby, assistant professor of community and rural medicine at CCHS, and Dr. Harriet Myers, an associate professor and clinical psychologist at the College, students explore social and cultural issues such as obesity, unemployment and insurance that impact public health and policymaking.
“That class was so beneficial,” Rainey says. “We talked about particular patients who impacted our week. They [Yerby and Myers] offered solutions or pointed to people who could. We talked about what the literature and science says about the subjects.”
Changing medical education
TLC² started with two pilot students in the 2014-15 academic year, and seven students participated in 2015-16. Beginning in 2018, all 34 third-year medical students at the University of Alabama School of Medicine’s Tuscaloosa Regional Campus will train through the program.
Yerby says one hope for TLC² is that students will emerge from it more empathetic toward patients. That seems to be happening.
“Seeing patients more than once really helps us see the humanity of medicine,” says student Courtney Crosby Newsome. “We learn in the classroom which treatments are best, but seeing what really works for patients over time comes out in this curriculum.
“Getting into a patient’s home life and mental health affects care and outcomes. Learning to treat a patient as a whole person, and not just a diagnosis, is the heart of what TLC² is about.”
To learn more about the Tuscaloosa Longitudinal Community Curriculum, see cchs.ua.edu/tlc2 or contact Krista Trimm at firstname.lastname@example.org or 205-348-9856.