Reinventing the Third Year of Medical School at UCSF

By Jennifer J. Salopek

In the late 1990s, the Office of Medical Education at the University of California San Francisco Medical School realized that the third-year curriculum, largely unchanged since the late 1890s, had to be transformed. Ann Poncelet, MD, who headed up the task force charged with the work, offers a dismal look back:

“Under the old apprenticeship model, we had a fragmented learning environment that offered no authentic role for students or for patients,” she says. “The result was a loss of patient-centeredness and moral erosion: Bright, skilled, empathetic doctors were not coming out the other end.”

Only one of two urban academic medical centers providing two tertiary care, UCSF had gotten complacent. “It’s harder for places that think they’re doing it well to feel a need for change,” Poncelet says.

Task force members developed the Parnassus Integrated Student Clinical Experiences program (PISCES), a longitudinal integrated clerkship program that allowed third-year medical students to follow their patient panels for an entire year. Its elements include interdisciplinary teaching, quarterly student evaluations with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. Launched in 2007-2008, PISCES is now in its ninth year. Technology innovations combine with curricular refinements to keep the program fresh and exciting.

“The challenge of an urban academic medical center is that very few generalists do swaps with other specialties to get breadth,” Poncelet says. “There’s also a mental block that this is only a model for primary care. We have lots of metrics to show that students are thriving.”

The LIC develops empathy and patient-centeredness skills in students. “We use reflective practice as a way to bring observations out into the open and make students decide intentionally what kind of doctor they are going to be,” says Poncelet. The longitudinal aspect of the curriculum is key, allowing students to develop relationships with patients. Patients are invited to provide feedback on students through the family practice clinic; survey results show that patients

  • appreciate that students explain things in language patients understand
  • appreciate the students see them as people, not just their illnesses
  • see that students help with transitions of care
  • feel that the clinic is a safe place to raise concerns.

“The students can be central to patients’ sense of well-being,” Poncelet says.

The program is innovative in that it provides relationship-based training on multiple levels – patients, preceptors, the student learning committee. For example, students observe preceptors and see how they struggle with situations and try to stay connected with the values that brought them into medicine in the first place. The program is piloting entrustable professional activities (EPAs), a concept launched by the Association of American Medical Colleges just last year.

Innovation also comes in the development and deployment of technology, such as an automatic pager system that alerts the students whenever one of their patients interacts with the system. UCSF is working to manage its electronic medical record to enhance students’ relationship with patients.

Third, the degree of patient empowerment is innovative. Patients are active participants in students’ education and in their own care, which changes their relationship with their doctors and with the health system, Poncelet says.

How can other medical schools adopt a similarly innovative mindset? “You just have to take the leap,” says Poncelet. “As students begin to see themselves as people who can transform the system, they can help to enact a complete transformation of the patient experience.”

Jennifer-1990-webJennifer J. Salopek is founding editor of Wing of Zock. She can be reached at, or follow her on Twitter @jsalopek.