Teaching Hospitals and Teaching Teachers

From The Practice January/February 2020
Clinical education models in medicine and teacher training

Law school clinics are perhaps bigger and more diverse today than they have ever been. As the lead article to this issue of The Practice lays out, clinics now span topics as diverse as housing, entrepreneurship, and immigration. Moreover, according to recent data from the Center for the Study of Applied Legal Education, nearly half of all law students participate in a clinic during their three years at law school. Clinical faculty numbers have also grown, as has their prestige. However, despite all the gains in clinical legal education, the fact remains that clinics continue to exist within—or perhaps alongside—the more traditional law school curriculum and faculty. Put differently, clinics are often treated as “bolt-ons” to a more traditional legal education, where courses like contracts, torts, civil procedure, criminal law, property, and constitutional law, taught by “podium” professors often using the traditional Langdellian case method, occupy the core of a law school curriculum.

In medicine, the term “clinic” (from the Greek klinē, meaning “bed”) often takes a more literal form with doctors visiting the bedsides of patients.

Other professions, however, treat “clinical” education in different ways. In this article, we move away from the law school campus in the hopes of learning from some outside perspectives, observing how other professions approach experiential learning as they endeavor to produce “practice ready” professionals in their fields. First, we look to medicine, where the term “clinic” (from the Greek klinē, meaning “bed”) often takes a more literal form with doctors visiting the bedsides of patients. Using Harvard Medical School’s curriculum as an example, we speak with Jane M. Neill, associate dean for medical education planning and administration, about how clinical experiences factor into medical students’ educations. We then turn to education itself, namely teacher training, to learn how theory and practice are mixed to prepare new teachers to take on all the responsibilities of maintaining a classroom from day one. We speak with Jesse Solomon, executive director and founder of the Boston Teacher Residency program, about how teacher education uses a clinical model to train future practitioners in real-world settings.

The cases of Harvard Medical School (HMS) and the Boston Teacher Residency (BTR) program challenge the legal profession to consider: How might we approach clinical legal education differently?

Clinical education as an integrated core: The case of medical education

Unlike law school, medical education has traditionally had a strong clinical component. Indeed, with the publication of the Flexner Report in the early 20th century, medical school typically involved two years of classroom learning followed by two years of clinical education, most often in a teaching hospital where physicians-in-training would go through a largely standard set of rotations (including surgery, OB-GYN, pediatrics, neurology, radiology, psychiatry, and medicine). These mandated clinical experiences were core to the medical curriculum, involving real patients under the supervision of practicing doctors-come-teachers. The current curriculum at HMS is both a reflection of this long history and an innovation from traditional structures. “Like many other medical schools, we were organized in a two-plus-two curricular structure,” explains Neill. Students would spend most of the first two years in the classroom followed by two years in the clinical setting—theory first, practice second. Now, HMS has moved to integrate the two, with clinical experiences starting in the first year and classroom experiences available in the final year (although, for the purposes of comparison, it is worth stressing that even traditional medical education includes two years in a clinical setting).

HMS’s doctor of medicine (M.D.) degree program, which typically graduates classes of fewer than 200 students, is divided into three phases: the pre-clerkship phase, the principal clinical phase, and the post-clerkship phase. As Neill points out, M.D. students’ clinical experiences are far from limited to the principal clinical phase of their program and instead are infused through the entire experience. “The initial phase used to be called the preclinical phase, but we have largely stopped calling it that because there is actually significant clinical education taking place in that foundational period,” says Neill. (Note: References in this article to HMS’s M.D. program and students primarily refer to its more traditional track rather than its Health Sciences and Technology track, which is geared toward students preparing for careers as physician scientists. For clarification, both programs lead to M.D. degrees at HMS.)

The centrality of the clinical component underscores the importance of the teaching hospital as an institution in medical training.

During the initial 14-month phase, M.D. students take courses like Immunity in Defense and Disease and Mind, Brain, and Behavior, as well as a longitudinal course called Practice of Medicine. As Neill describes, this longitudinal course is an M.D. student’s first introduction to clinical practice. Students are paired with practicing primary care physicians whom they shadow one day a week for a full year. “During this course, students are learning a lot of the basics of patient care,” Neill notes. “On a regular basis they are in the office of their preceptor—that is, the primary care doctor—seeing patients, building relationships with mentors, and learning about the practice of medicine from very early on in medical school.”

Once they get past that initial phase—which Neill stresses is 14 consecutive months—students move on to the principal clinical phase that constitutes a full year at one of the major teaching hospitals affiliated with HMS. In that time, students are completing eight required “clerkships,” or rotations, in which they apply the knowledge gained through the first phase of their medical education. Seven of those required clerkships—surgery, OBGYN, pediatrics, neurology, radiology, psychiatry, and medicine—are consecutive, each ranging from four to 12 weeks. One clerkship, primary care, extends longitudinally throughout the year. M.D. students “go to class” in hospitals, operating rooms, and doctors’ offices. Real patients are their primary textbooks, and practicing doctors are HMS faculty. During that year, students also engage in longitudinal modules, from case conferences to seminars and discussions. As Ed Hundert, the dean for Medical Education at HMS put it in a curricular video, “The PCE year is one of the most memorable of medical school, and it’s a time when students develop increasing competence and confidence in their clinical skills and begin to explore different types of medicine that might attract their passion and interest.”

The centrality of this clinical component also underscores the importance of the teaching hospital as an institution in medical training. From the beginning of their training—indeed, at HMS, in the very first year of medical school—M.D. students are members of teams of medical professionals designed to train them in real practice settings. Teaching hospitals provide these training sites that cultivate the future of the medical profession while at the same time caring for patients. And, far from serving as second-rate institutions from a patient-care perspective, a recent study has shown that on average teaching hospitals outperform nonteaching hospitals on crucial metrics like mortality rates. Among the teaching hospitals to which HMS sends its M.D. students are Mass General and Brigham and Women’s, two of the top hospitals in the country—teaching or otherwise. The training does not diminish care but is baked into the system that simultaneously treats patients and trains M.D.s.

Physician training is not complete when they graduate medical school—indeed, they are only then just entering the postgraduate training phase of their careers.

In the third and final phase, M.D. students at HMS are doing a mix of clinical and other coursework and scholarship (including a required scholarly project). The clinical aspect is often done through advanced clinical electives, which are intended to build on M.D. students’ experiences during their principal clinical phase. As electives, students use them to explore a specialty they have in mind for their career and may also approach these clinical opportunities as chances to temporarily step outside their preferred area of clinical interest. However, because M.D. students all have a common core of clinical experiences under their belt, these electives function as just that: electives.

Neill is careful to note that while each medical school approaches its curriculum in its own way, all emphasize the importance of firsthand clinical experience as critical to understanding how to be a doctor. That message is then reinforced when graduates enter the tiered structure of the larger medical profession. After all, physician training is not complete when they graduate medical school—indeed, they are only then just entering the postgraduate training phase of their medical careers.

New M.D.s begin their careers and continue their training in hospitals on teams that commonly include M.D. students, interns, residents, fellows, and attending physicians. When M.D. students graduate, they continue with three or more years of postgraduate training in residency programs in their chosen specialty. Throughout the progression, those with more seniority will supervise and guide those with less seniority, with each member’s responsibilities and capabilities growing over time. After these phases—noting, however, that states vary regarding many years of postgraduate training are required for initial medical licensure—individuals can get their full medical license pending exams and other requirements. Attending physicians may also go on to pursue further training and certification in a subspecialty and board certification, which is optional, as a means of demonstrating mastery of their field.

More changes are under consideration for HMS’s M.D. curriculum. In The Practice’s conversation with Neill, a word that kept coming up was “longitudinal,” which could be the way of the future for clinical medical education. While there is already a heavy dose of clinical work in the current setup, Neill notes that most clinical experiences are in inpatient settings, where patients are acutely ill, and not over the life cycle of their care, which could ultimately limit the pedagogical value of those experiences. “We’re going to be working on an initiative to build more opportunities for students to see patients longitudinally,” affirms Neill. She explains:

A lot more of medicine now, especially patients who aren’t acutely seriously ill, is being practiced in the outpatient setting, which provides students a lot of opportunities. First, they might be able to see a patient in the outpatient setting before the patient’s diagnosis has been made so they can participate in the process of developing a differential diagnosis and figuring out what’s wrong with the patient. They can see the disease unfold over time in the outpatient setting as opposed to seeing a patient who’s been admitted to the hospital for a couple of days to take care of something that’s happened to them acutely. Forty years ago, patients were admitted to the hospital and they might be there for a couple of weeks. That doesn’t happen very much anymore, and that is why medical education has to continually be evolving.

HMS has already implemented this approach with its Cambridge Hospital longitudinal integrated clerkship, where M.D. students experience their clerkships contemporaneously over the course of a year rather than one at a time. Currently, cohorts for this longitudinal clerkship model at Cambridge Hospital are small (about a dozen students) and determined by an opt-in lottery, but consideration is being given to longitudinal experiences more widely in the principal clinical year. This, Neill suggests, is part of the process of ensuring that students are being prepared for the profession that awaits them. “The field of medicine, as I’m sure is true for law, has some foundational content that doesn’t change,” she says. “But discovery and treatment are in a continuous state of evolution, so the curriculum needs to evolve, too.”

Building competence: How teacher education bridges theory and practice

Like law and medicine, teaching brings with it a significant degree of responsibility. Teachers are charged with not just the care of several or dozens or even hundreds of individuals (often children) but also with designing and executing curricula that will prepare those individuals for their futures. And, like law and medicine, how teachers are trained to take on that responsibility presents ethical challenges, not least of which is ensuring that new teachers are prepared to fill the role as soon as they take charge of their first classroom. That is why many teacher education programs—which are often required for licensure and which themselves often require “clinical” experience in the classroom—include what is called a “practicum,” or a component that puts aspiring teachers in real classrooms as part of their training. The BTR program is both a reflection of the rich tradition of the practical training in teacher education as well as an innovative extension of that model in a way that emphases the importance of practice from day one.

The objective was to integrate theory and practice in a way that exposed students to real-world practice earlier in their training.

Historically, BTR’s Jesse Solomon notes, this practical component has existed separately from traditional classroom learning within teacher education programs. “For a long time, education schools would essentially front-load all the theory before sending someone into a class,” he says. “And there is often a divide between what a novice is being taught in the university classroom and what that novice’s mentor teacher says.” He explains:

University professors may essentially be saying, “Don’t pay attention to the practice you see in your host school during your practicum—it’s not good teaching.” While the teachers in those schools are saying, “Don’t listen to your university professors because they haven’t been in a classroom in 30 years.” The key is getting the two to speak to each other, and overall I think the field is moving in a positive direction toward having teacher preparation in general be much more clinical and practical.

To help push the teaching profession in that direction, partnering with Boston Public Schools, Solomon helped found the BTR program in 2002 to provide teacher training that emphasized this merger of theory and practice. Like HMS’s recent curriculum changes, the objective was to integrate theory and practice in a way that exposed students to real-world practice earlier in their training to avoid the disjointedness Solomon describes above. At its core, BTR combines a yearlong classroom practicum with master’s-level course work that effectively provides teachers with a Massachusetts teaching license, the opportunity for an M.Ed. (as part of the BTR program and awarded through the University of Massachusetts Boston), and the ability to coteach and collaborate with experienced teachers to prepare them for their careers ahead. However, as Solomon notes, because the state ultimately decoupled the master’s degree from licensure, there was “a lot more room for innovation.” Even those who pursue the master’s degree need never leave the residency program for a college classroom. BTR hires its own faculty and designs its own full curriculum of courses. To correspond with a traditional school year—when the program prefers its participants to be in live classrooms coteaching—all course work is done on Fridays, during the summer, or in the evening. Moreover, these courses are taught by experts brought in by BTR with a demonstrated ability to bridge theory and practice.

To illustrate the need to firmly link theory and practice, Solomon uses the example of independent reading, an activity where each child is reading something different depending on his or her interest and reading level while supervised by a teacher. “There’s certainly a lot to know about reading development from the research side,” he notes. “But there’s only so much you can do in the college classroom. In practice, you might have 25 kids doing independent reading and you’re just one person. The trick is how to get around the room to apply all that theory. There’s an art and science to having those conferences with each student.”

Like the medical student working in a team of more-experienced professionals, mentor teachers assessing student teachers’ performance and progress is a critical component of any practicum. While each teacher will have his or her own distinct style and voice, there are still baseline skills that all student teachers need to take away from their program. Their ability to lesson plan, design and execute learning objectives, facilitate discussion, design assessments, effectively initiate and finish class, and collect and use information from past classes to inform future classes—all are necessary skills for a teacher that are honed and assessed in the practicum setting. As Solomon notes, “Our program is designed around a set of competencies that they have to demonstrate in order to graduate. If they can’t demonstrate them, they don’t get licensure.”

In both forms of professional training, the application of theory is treated at least as seriously as the theory itself.

Notably, student teachers often need to be eased into a primary teaching role—what Solomon calls a “release of responsibility.” Where the medical curriculum might add clinical experience in chunks—a four-week rotation in neurology, an eight-week rotation in surgery, and so on—BTR might instead approach its practical elements through a steady, gradual immersion into the practice of teaching. In most any practicum setting, there will be at least one mentor teacher and one student teacher. Over the course of the practicum, the mentor teacher will hand the reins over to the student teacher while offering guidance and feedback. As with the medical profession, a fully licensed professional is present in the clinical setting to support the professional-in-training but also to provide a quality check on behalf of the students for whom they are ultimately responsible. However, far from simply providing a “trained professional in the room,” having at least two teachers—a mentor teacher and a student teacher—actually opens up new possibilities for lessons and activities. Thus, owing to this setup, which is in many ways contrived for the purposes of teacher training, classes might be able to alternate nimbly between lectures, guided smaller group discussions, and even more-individualized learning that might not be feasible with only one instructor presiding. The teacher-in-training becomes a strength of the classroom, not a weakness.

Quality metrics in teaching

One challenge in the teaching profession, not unlike the law, is a lack of consensus metrics to measure the quality of teaching in a way that can inform discussions around how to better train teachers for the future. Statistics on teachers are available that might indicate a positive or negative impact on students’ learning environment, such as teacher retention, but measuring the effectiveness of teaching in a way that allows for apples-to-apples comparisons remains somewhat elusive. “I’d say that’s the Holy Grail—certainly for our program and I would think it’s true for the profession in general—to really get to a point where we measure student outcomes,” says Solomon. “This is something that the field is still grappling with.” Standardized tests are available in different forms depending on the state; however, these measurements are often controversial and infrequent.

In addition, some standardized data on the teachers themselves might be available at the state level, but Solomon cautions that the takeaways here are limited, too. “Here every first-year teacher gets evaluated using the same rubric in the state, which is actually quite helpful for our program,” he says. “This allows us to know that our teachers are represented in the ‘highly qualified’ category at twice the rate of the average of people in the rest of the state, but of course that doesn’t really tell us anything about student outcomes.” In other words, gauging the quality of teaching still relies to some degree on input-based metrics, creating challenges for defining clear strategies to improve teacher training and performance.

Questions for law schools

Through medical and teacher education, we see two models of “clinical” training for professionals. With HMS, the clinical component is integrated into the core of the curriculum. With the BTR program, the practicum component is introduced early and responsibility is slowly released to student teachers as they gain competence. In medicine more broadly, the M.D. student is the most junior member of a team of attending physicians, fellows, residents, interns, and others. In teacher training, the practicum is often defined more by one-to-one master-apprentice relationships between the mentor teacher and the student teacher. In both forms of professional training, the application of theory is treated at least as seriously as the theory itself.

Of course, medicine, teaching, and law are all vastly different professions with different sets of responsibilities and different types of “clients.” But these two examples raise questions worth exploring in a legal profession context: What would a law school curriculum with an integrated clinical core look like? What are the challenges and benefits of slowly but steadily immersing law students into real-world practice? How could the profession build a structured postgraduate training system? What else is possible with clinical legal education?