Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Takeaways from the book “Progress Notes” 


Excellent clinicians understand patients not just as bodies, but also as individuals within a community. Healthcare professionals should be trained in both for a more holistic approach to patient care. 

Catherine taught school, Itzam played professional soccer, Megan was a doula, Mallory read philosophy, Mackenzie was an advocate, Maggie served the homeless, and Sarah fixed bikes. Then these seven students, like 60,000 plus students every year, applied to medical school. When they enrolled, they joined more than 22,000 young people starting medical school in the United States each year. Most of these students will train, like me, on the textbook of the body. 


Since the 1910 Flexner Report, medical students have followed physicians through a series of hospital-based clinical clerkships: internal medicine, obstetrics, pediatrics, psychiatry, and surgery. This training model focuses on acute ailments and isolated injuries, on knowing the human body from the inside out. It’s a textbook of the body approach. But it’s not designed to teach learners about caring for those who are chronically ill or suffering illness because of any number of social problems. These include inadequate housing, unemployment, lack of transportation, no access to healthy food, and lack of public safety. These societal problems bring people to the hospital. We’re suffering from the endemic illnesses that sicken us, slowly, from the outside in: anxiety, depression, diabetes, heart disease, obesity, substance abuse, and suicide. To treat those, leading educators say medical students need to learn the textbook of the body and the textbook of the community. 


So, I followed Catherine, Itzam, Megan, Mallory, Mackenzie, Maggie, and Sarah as they embarked on an experiment in medical training. Following them in lecture halls, operating rooms, trauma bays, hospital wards, and clinic rooms for a couple of years renewed my hope in medical education for patients, trainees, and faculty to flourish. 


From these remarkable seven students, I learned the value of: 


1. Continuity      

Flexner wrote the cadaver lab was “where the wise were brought to book” because it was the only place a student could learn about the body. Today’s students have immediate access to medical knowledge that Flexner could never have dreamed of. What they need is continuity with each other, with their faculty, and with a small group of patients they follow over time. 


2. Two textbooks  

Medical students should continue to learn the textbook of the body in the ways only a research university can teach—through rigorous investigation, innovative scholarship, and scalable delivery systems—while also learning the textbook of the community. Health professionals at all levels need to know how they can help their patients address the cultural, economic, and social factors which so deeply affect health. 


3. Scalable change 

In national studies, learning the two textbooks improves student communication skills, increases clinical reasoning, teaches students to be patient-centered, all of which results in better student satisfaction and exam scores than traditional clerkships. So, the idea has spread—from a sketch on a coffee shop napkin to medical schools in Australia, Canada, Ireland, New Zealand, Norway, Singapore, South Africa, and the United Kingdom. Medical students around the world are being trained to accompany their patients. 


My new book “Progress Notes” follows seven medical students in a longitudinal integrated clerkship (LIC) based at the University of Colorado School of Medicine. It narrates how the LIC students learned from two textbooks by being rooted in a small community of learners, following a cohort of patients over time, learning together through team-based learning events, and visiting patients in their own homes. 


While studying the two textbooks, they also live their lives: marrying, parenting, and becoming ill themselves, all while they develop into the kind of physician they’ll be for the rest of their lives . . . and the kind of physician they will be for others. 









This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.