As I was reading about the early years of the Department of Psychiatry of the Perelman School of Medicine recently, I came upon a surprising case of anticipation. Learning about a new program -- in 1949 -- reminded me once again that some ideas are good enough to go around more than once.
In Two Centuries of Medicine: A History of The School of Medicine, University of Pennsylvania, George W. Corner, M.D., Sc.D., LL.D, covered an immense amount of material in the space of some 320 pages, not counting notes, references, and index. The school’s founding occurred in 1765, when John Morgan read his Discourse upon the Institution of Medical Schools in America, at the Commencement of the College of Philadelphia. It was that presentation, quickly issued in pamphlet form, that led that same year to the establishment of the first medical courses in the nation. At the other end of the book was a glance at what Corner called “the past twenty-five years” -- that is, up to 1965, when the book was published. It was a program proposed during that period that caught my eye.
As Corner described it, Penn’s curriculum was undergoing changes at the time, primarily through scientific additions, but he also singled out two programs “aimed at bringing back something of that direct contact with ailing human beings outside the school which was the advantage of the old apprenticeship system.” In 1949, Kenneth E. Appel, professor (and later chair) of psychiatry, and John McK. Mitchell, professor of pediatrics and dean of the school, “suggested a novel means of helping medical students to learn the physician’s role in family and community life. . . . [T]he Family Health Advisory Program initiated by Mitchell and Appel was unique in that it begins in the 1st year of medical study and introduces the students to the whole range of medical problems in underprivileged households.”
Each student who elected to take the course was assigned to a family for whom he served as “health advisor” for two years or, if he chose, through the whole four years of medical school. (The “he” was Corner’s word, a choice recognizing how few women attended medical school at the time.) “Observing the same group of people through a long period, in all their reactions to illness and other stresses, he advises the family about services available through the hospital and other communal agencies and translates to these people the diagnoses made and the treatment prescribed by the hospital staff.” Here, “translate” has little to do with the current “translational” but is meant literally: putting what is said into “plain English” that patients could understand.
Corner’s history ended too soon for us to know what happened to the program, and it does not appear in the later Innovation and Tradition at the University of Pennsylvania School of Medicine (1990). But in certain ways, the Family Health Advisory Program resembles a later program developed by the School of Medicine. The Longitudinal Experience to Appreciate Patient Perspectives (LEAPP) program was launched in 2004 and is still going strong. First-year students are assigned in pairs to patients with chronic illnesses. They follow the patients and their families for three years, in contact with the patients in their homes (where, for instance, they may go over a patient’s prescriptions), in their doctors’ offices, and in the hospital, if that step is necessary.
As Paul Lanken, M.D., professor of medicine and medical ethics and associate dean for professionalism and humanism, told Penn Medicine magazine soon after the program began: “Most people don’t think of how difficult the first year of medical school can be. The students are asking themselves, ‘Am I sure I want to be in this med school business? I’m not seeing patients at all.’ They’re sitting in lecture hall and labs for seven, eight hours a day -- that is not why they are in medical school.” What these students were seeking is the “direct contact” with patients that the earlier program was designed to provide.
The LEAPP program was considered unique both because it involves first-year students (as the earlier program did) and because it is required of all medical students (whereas the earlier program was an elective). But the resemblances are strong in that both provided early clinical experiences and sought to enhance humanism and professionalism while focusing on the patient. LEAPP students report building unique relationships with their patients while learning about the larger context of illnesses and their effects on families.
A similar case: students from the Perelman School have been serving the community by helping to staff clinics in West Philadelphia: the University City Hospitality Coalition (since 1984) and the United Community Clinic (since 1995). With students and staff from other professional schools, they offer screenings and many other free health services to those who may not otherwise receive such care. What I learned when Penn Medicine ran an article on these clinics and the students who help run them is that Penn medical students had organized something very much like the community clinics 50 years earlier.
Back in 1949, the impetus came from members of Penn’s Christian Medical Society, who established clinics for the homeless at the Central Gospel Hall Mission and at the 8th Street/Wayside Mission. As a publication at the time put it, they were “providing care and thoughtful treatment” to the needy. Soon, students who were not part of the Society were permitted to join in providing care. As today, the students in 1949 had physician guidance. In fact, the second graduate director of the earlier clinics was C. Everett Koop, M.D., the future Surgeon General of the United States, then an assistant professor of surgery at Penn and surgeon-in-chief at The Children’s Hospital of Philadelphia.
Good ideas can have different incarnations at different times.