Medical students Melanie Ma '17, left, and Allie Brown '17 (Photo: LCOM Creative Services)
It was only the third day of her first-ever Clerkship rotation – internal medicine at Norwalk Hospital in Connecticut – and Class of ’17 medical student Melanie Ma witnessed a patient go into cardiopulmonary distress and die. “I felt pretty helpless,” says Ma, who was unsure of her role, as a medical student, in the situation. Compelled to reflect on and process what had happened, she discussed the experience later that day with her roommate and Larner College of Medicine classmate Allie Brown ’17.
Neither student had undergone training to prepare emotionally for this type of scenario, but they now had proof it was needed. The beginnings of a curriculum plan were set into motion.
“What we like about UVM is that the faculty and administration will listen with open minds to students’ input on the VIC,” say Ma and Brown. “If you have an idea about how you want to do it – a plan – you’re encouraged to move forward with your initiative.” Both students were leaders of the College’s American Medical Women’s Association Student Interest Group, an experience they say encouraged them to pursue scholarly interests and connected them with faculty who could provide guidance and support.
After talking with Foundations Course Director Paula Tracy, Ph.D., and Doctoring in Vermont Course Director Dennis Beatty, M.D., they contacted the Dana Medical Library to do a literature search for publications on this type of medical student training, but there were no examples.
“Melanie and Allie saw a hole in the curriculum – in this case, proper preparation for witnessing a cardiac arrest and dealing with the feelings that follow – and they filled it,” says Laurie Leclair, M.D., associate professor of medicine and course director, Cardiovascular, Respiratory and Renal Systems.
With support from Cate Nicholas, Ed.D., M.S., P.A., director of simulation education and operations, as well as Professor of Psychiatry Terry Rabinowitz, M.D., Professor of Pediatrics and Medical Director of Clinical Ethics Robert Macauley, M.D., spiritual care professionals, and Leclair, who served as their Scholarly Project advisor, Ma and Brown developed a simulation scenario for a code.
The “Mock Code” curriculum for third-year medical students was piloted during the Class of 2018’s orientation week for Clerkship in 2016.
In the scenario, which features a code team, critical care nursing staff and SimTerns, students “witness a simulated code and then dissect their emotional reactions to the experience with a panel of experienced clinicians who are all Larner College of Medicine faculty,” says Ma.
For the pilot session, which lasted one hour, Brown and Ma provided a short introduction to the simulation scenario, letting students know they would be witnessing a simulated code and it would be acceptable if they needed to leave the room during the experience. The Class of '18 students were given a form and received an introduction to the patient, which included a name, past medical history, presenting illness, hospital course, and, most importantly, social history, with the aim of creating a connection between the students and the patient. Then, they were left in silence for 10 seconds to process the information. Finally, the code team ran a code for seven minutes and the “patient” died. After the code, the team left for a few seconds.
Brown and Ma told the students to “use the paper in front of you to write one word that describes how you feel right now.” After that, the students were able to initiate an open discussion with a panel featuring Macauley; Rabinowitz; Father John Crabbe, manager of spiritual care at UVM Medical Center; Leclair; Ma; and Brown.
At the end of the session, participants received a post-session questionnaire and received a list of mental health services available to students at each affiliate clinical training site. Out of approximately 113 participants, 105 provided feedback. The response was extremely positive.
“The thing I love most about this session is it was designed by students for students,” says Leclair. “This work has been presented at the Teaching Academy’s Snow Season Retreat and has been accepted to be presented at the AMWA national meeting in early April 2017.”
The next session will run during the Class of 2019’s Clerkship orientation week in March. Ma and Brown, who have been working on abstracts and a manuscript for publication, will be joined by four junior medical students in delivering the course and moving it forward.
Ma’s experience has been a conversation-generator on the residency interview trail, and has garnered interest in the curriculum. She and Brown both felt that UVM would be open to piloting this course in its curriculum because of the school's attention to student well-being and they believe that all medical students could benefit from a course that allows for reflection on how witnessing a code affects them. “UVM is so focused on student wellness; it makes you a more skilled, effective physician,” says Brown.
The soon-to-be M.D.s hope that as a result of their course, Larner medical students will be better equipped to deal with both the intellectual and emotional aspects when they witness a code.
“In terms of wellness, [this curriculum] provides a tangible example of medical students taking care of their own, of taking the necessary steps to try to lighten the emotional load for their colleagues,” Leclair says.