Preparing schools for the worst-case scenario

A Yale pediatrician trains educators in New York and around the world to help children cope with crisis.

In a hotel conference room last April in New York, Yale pediatrician David J. Schonfeld, M.D., guided 100 school counselors, teachers and administrators through a hypothetical school crisis: the star of a high school play has died of cancer, and classmates hold a fund-raiser in her memory to benefit medical research. When a television news team covers the event, they learn that a second student had died of the same form of cancer. They also report that toxic substances have been found in the soil around the school.

The next day half the student body is absent, and the school is surrounded by reporters; finally, the principal says that she has been diagnosed with another form of cancer.

Working in teams, Schonfeld’s audience had to respond to each stage of the crisis. They discussed how to determine whether there were any health risks to students and staff; what to tell staff, students, parents and the press; and how to support the students, the principal and other staff. The teams had 10 minutes to spring into action, the same deadline many New York City educators faced on September 11, 2001.

In fact, the attacks on the World Trade Center were a major reason for the exercise. New York City school officials had asked Schonfeld, an associate professor of pediatrics with an appointment in the Child Study Center who has been helping schools deal with crises for more than a decade, to train response teams that include educators, administrators, mental health professionals, nurses and safety personnel from the city’s approximately 1,200 schools. Along with Scott R. Newgass, M.S.W., and David Szydlo, M.D., Ph.D., Schonfeld provided more than 50 full-day workshops for teams from throughout the school system. With colleagues at the National Center for Children Exposed to Violence (NCCEV), he also developed guides for talking about 9/11, the anthrax scares, the war in Iraq and death.

Though the participants in the cancer-scare scenario groaned with each mounting crisis, they found the discussion instructive. Most had lived through 9/11, when administrators had to decide whether to send children home amid the chaos. Parents flocked to schools seeking not only their children but also information. News spread by word of mouth, more distorted with each telling. Teachers waited for hours with students who had no way to get home. And educators had to explain to children why this was happening while grappling with their own distress.

“It was hours and hours of dealing with things you never could have anticipated,” said Janet Hughes, a Bronx high school principal. “There were a lot of things on the school level that people were just not prepared to deal with.”

And not only in New York. Educators around the world are thinking more about how to help children cope with disasters, including plane crashes and earthquakes, as well as political violence. Schonfeld has also provided training in England, Sweden and Israel; in March 2003, he provided a series of workshops in Osaka and Tokyo as part of the establishment of Japan’s National Mental Support Center for School Crisis.

Ten years ago Schonfeld was running the School Crisis Prevention and Response Initiative in New Haven, with an eye to designing a national model. Today that model is in place as part of the NCCEV at the Yale Child Study Center. NCCEV grew out of the Child Development-Community Policing Program established by Steven Marans, Ph.D., the NCCEV’s director, and the late Donald J. Cohen, M.D. ’66, who led the Child Study Center from 1983 until his death in 2002.

Schonfeld’s model is broad enough to help guide children through a range of events. It helps educators plan for the needs of children and school staff at a time of crisis. It also aids schools in identifying and addressing symptoms of emotional distress and devising memorial events that are meaningful and healing. And the model emphasizes the importance of letting students vent. “When comments or questions come up naturally, if the teacher is ready for them, there can be useful discussion,” Schonfeld said.

Schonfeld wants to bring mental health needs into the mainstream of pediatric medicine. As the physical health of children has improved, attention in pediatrics has shifted to developmental and behavioral concerns, a relatively new area of specialization. Yale’s Department of Pediatrics recently created a subsection for developmental-behavioral pediatrics, and it is the site of one of nine fellowship programs funded in July 2003 by the Maternal and Child Health Bureau, an agency of the Department of Health and Human Services, for training in the emerging discipline.

In November 2002, the American Board of Pediatrics offered the first exam for certification in the field, but Schonfeld wasn’t immediately eligible to take it, despite his obvious familiarity with the topic. He, along with other members of the subspecialty board, had to take a different test—one that they hadn’t written themselves.

—Anne Thompson

In gleaming anatomy lab, more room to work and a new way of teaching

When the 100 students of the Class of 2007 donned their scrubs and rubber gloves on September 5, they became the first group to study anatomy in the new labs at the Anlyan Center for Medical Research and Education. As first-timers they had no point of comparison for the brand-new, shining, stainless steel facilities. But to anyone who has ever set foot in the old dissection rooms, one change was obvious.

“I’m working without a mask,” said Lawrence J. Rizzolo, Ph.D., associate professor of surgery and course director. He was, of course, referring to the strong odor of formaldehyde—or lack of it—in the new lab. Each station has a vent that draws odors out, and that drew a word of caution from William B. Stewart, Ph.D., associate professor of surgery and chief of the anatomy section. “The last thing you ask yourself is, ‘Did I turn the vent off?’ Because if the vent is on 24 hours a day, your cadaver will be sucked dry,” he said.

Rizzolo delighted in another difference—more space. “I can walk between tables,” he said.

The extra space and absence of strong odors are more than mere creature comforts. They’ve led to a change in the study of anatomy. “Students often come back to work extra hours,” Rizzolo said. “In the old lab your eyes would get itchy and your throat would get scratchy. The odor made you sick to your stomach if you stayed a long time.”

The tables are bigger and there are more of them—40 as opposed to 32. That means each dissecting station has four instead of five students. (Although only 25 tables are needed for medical students, others are used by the Physician Associate Program, residency programs and other institutions, such as Quinnipiac University, which don’t have their own anatomy facilities.) Computer terminals, which were being installed at each station during the fall, will allow students to refer to online resources while they are dissecting. “If a question comes up at the dissection table, the instructor can just say, ‘Let’s look at the computer resource,’ and make a point you can’t make if the computers are 10 steps away,” Rizzolo said.

Perhaps the biggest change for the first-year anatomy course has been the creation of what the faculty call “learning societies” within the class. Each is made up of 20 students and a mentor. “The idea is for these groups to develop a sense of community and share each other’s work,” Rizzolo said. “In the old labs, where everyone was standing on top of one another and it was hard to move around the lab, students would look at their own dissection and not look at who was next to them. … The geography of the lab has allowed us to organize this massive number of students into manageable groups that then become a community.”

—John Curtis

Clinical-skills course prepares students for the wards and a new Step 2

Medicine became very personal for Jessica Kattan, a second-year student, shortly after she took a patient’s history. “I figured he probably had the flu,” Kattan said. But tests revealed Burkitt’s lymphoma, a rare and aggressive form of cancer.

“The next time I saw him, he was very ill from his chemo,” Kattan remembered. “Before that, this disease had just been some words in a book to me.”

Kattan’s experience was part of the “Doctor-Patient Encounter.” Now called the “Preclinical Clerkship,” it is a two-year course aimed at teaching skills that students will need to care for patients when they begin their clinical rotations. Margaret J. Bia, M.D., who has directed the course since 1999, sums up its content as the heart of “doctoring”—sensitive interactions with patients, thoughtful diagnoses and effective treatment plans.

For the past five years, Yale students have had their history and physical exam skills assessed at the nearby University of Connecticut assessment center at the end of their second year. This year, students are returning to the center at the end of their third year for an assessment of history and physical exam skills.

Students will also have to demonstrate their mastery of these skills on a new national exam that all medical students must pass in order to obtain a medical license. The exam, a new, second component of Step 2 of the United States Medical Licensing Exam (USMLE), will be required of all medical students graduating in 2005.

This emphasis on skills assessment is part of a national movement recognizing the importance of clinical skills in medical training and clinical care. According to a Harris Poll, two-thirds of Americans support the new national exam, a one-day test that strives to replicate a typical doctor’s work day. Students will examine 10 standardized patients—actors feigning symptoms and ailments—and formulate diagnoses and treatment plans.

The board that oversees the USMLE sees this as a matter of public safety, since good clinical and communication skills correlate with a lower incidence of malpractice suits, better treatment compliance and greater patient satisfaction. Slightly more than half of the medical schools in the United States now require a clinical-skills exam before graduation, yet a survey by the USMLE found that 4 percent of medical students had never taken a history or conducted a physical under the tutelage of a faculty member.

The exam is meeting resistance from the American Medical Student Association, because it will increase students’ debt burdens by $975, the cost of the exam, plus expenses to travel to testing sites—Philadelphia, Atlanta, Chicago, Los Angeles and Houston.

The new exam reflects a change from times past, when students picked up their clinical skills in large part by observing physicians. “Now we have 20-minute clinic visits, which markedly reduces the available time for students to practice and receive feedback,” Bia said.

The “Preclinical Clerkship,” taken in the first two years of medical school, fills that gap with weekly sessions that emphasize history taking and physical examinations. Students work with faculty to develop specific skills and meet weekly with clinical tutors who observe them taking histories and performing physical exams. Students learn communication skills—history taking, social history taking, breaking difficult news—in workshops where they practice on standardized patients before seeing real patients.

“Hopefully these developments in clinical-skills acquisition and assessment will lead to students graduating with a greater mastery of the skills they need to be compassionate, competent physicians,” Bia said.

—Colleen Shaddox

Honoring an NMR pioneer

A June symposium, “From Molecules to Mind: Celebrating the Contributions of Robert G. Shulman to Biological NMR,” honored Robert G. Shulman, Ph.D., Sterling Professor Emeritus of Molecular Biophysics and Biochemistry, for his use of nuclear magnetic resonance (NMR) to study metabolic pathways in live subjects. Shulman, a pioneer in magnetic resonance research, has used high-field NMR spectroscopy to follow chemical reactions and brain activity and to develop methods for localizing brain function. The symposium drew researchers and colleagues from around the world.

—John Curtis

For interns, a place to eat pizza and unload the stress of a frenetic first year

“Do I know enough to care for this patient?” “I feel so out of touch with the rest of the world.”

These thoughts are likely to pass through the mind of the typical intern during the first year of residency, a whirlwind time that has a component of self-doubt accompanying rapid learning and maturation. In the past, interns kept such worries to themselves. But at the Waterbury Hospital Health Center, 20 miles north of New Haven, first-year residents gather at noon each Friday to compare notes on the challenges and rigors of training.

The lunchtime talkfest is led by Seth R. Segall, Ph.D., director of psychology at Waterbury Hospital, and Auguste H. Fortin VI, M.D., M.P.H., director of the psychosocial curriculum at Yale’s Primary Care Residency Program. Fortin, who said he was “concerned that the house staff didn’t have a forum to share the feelings and the stresses of being an intern,” began holding the weekly meetings with Segall three years ago.

What is said in the room stays in the room. Over pizza and Pepsi, the interns talk about the issues that affect them on the ward—the death of a patient, the fear of an accidental needle stick, the grueling schedule that can lead to marital stress. “This is not a regular life,” said intern Juanita Smith, M.D., “so if you have other people around you who say, ‘Yes I feel that too,’ it makes you realize that your feelings are normal for the context that you are in.”

Segall starts each session with a few moments of meditation. “We’re training physicians to listen to themselves,” he said, “and I think that will help them to be more compassionate doctors.” Fortin would like to expand the program to Yale’s other primary care residency training hospitals, St. Mary’s in Waterbury and Yale-New Haven.

—Lisa Quirindongo

Et cetera

Late neuroscientist honored

In recognition of her pioneering work on the brain’s frontal lobe and her studies of the cerebral cortex and its links to schizophrenia, the National Alliance for Research on Schizophrenia and Depression (NARSAD) has created a prize to honor Patricia S. Goldman-Rakic, Ph.D., who died in July after being struck by a car. And in November, Pfizer announced that it will fund a graduate fellowship in neuroscience in honor of Goldman-Rakic, the Eugene Higgins Professor of Neurobiology. Each year, an outstanding graduate student in the Combined Program in Biological and Biomedical Sciences will receive full support for a year’s study.

NARSAD announced The Dr. Patricia S. Goldman-Rakic Memorial Prize for Cognitive Achievement in Neuroscience in October. The annual $40,000 prize will reward “excellence in neurobiological research at the cellular, physiological, or behavioral levels that may lead to a greater understanding of major psychiatric disease.”

The first recipient of the award is Solomon H. Snyder, M.D., chair of neuroscience at Johns Hopkins and a longtime friend and collaborator of Goldman-Rakic. Snyder discovered the role nitric oxides play as a class of neurotransmitter in the brain and created techniques for understanding and manipulating brain receptors.

—John Curtis

Chagas drug licensed to nonprofit

The nation’s first nonprofit pharmaceutical company has licensed a new class of compounds from Yale and the University of Washington that could lead to treatments for the parasitic Chagas disease, which affects between 16 and 18 million people, mostly in Latin America.

The compounds, called azoles, were developed by teams led by Andrew D. Hamilton, Ph.D., deputy provost for science and technology at Yale, in collaboration with faculty at the University of Washington. Azoles inhibit production of a chemical that is necessary for the survival of the parasite Trypanosoma cruzi without harming human cells.

The Institute for OneWorld Health in San Francisco will have exclusive license to develop azole compounds.

—John Curtis


			Originally published in Yale Medicine, Winter 2004. Copyright © 2004 Yale University School of Medicine. All rights reserved.