91´«Ã½

Abraham Nussbaum, Postbac ’99, is the author of Progress Notes: One Year in the Future of Medicine. Published this fall by Johns Hopkins Press, the book follows a group of medical students who train by following patients instead of physicians in a longitudinal integrated clerkship (LIC) model at Denver Health, where Nussbaum is the Chief Educational Officer.

Accompanying them to primary care appointments, emergency room visits, and procedures, the students develop deep connections with the patients and see the healthcare system through their eyes, charting a new future for medical education and training.  

We asked Nussbaum more about his book, about the Postbaccalaureate Premedical Program training at 91´«Ã½, and how it changed his life in many ways—most of all by leading him to cross paths with his wife, Elin Kondrad '99.

Tell us about yourself and what brought you to medicine.

I grew up in Colorado and went to college at Swarthmore. I wanted a rigorous liberal arts school training, and I wanted to live in a beautiful place. There’s something really beautiful about a Pennsylvania spring.

I studied religion and English lit there—I had no intention of going to med school, but I had a classmate who become very ill, and I saw how people fall out of the human community when they get sick. I was headed on a pathway toward grad school in religion, and that kind of derailed it. I decided to spend a year doing AmeriCorps on the west side of Chicago and worked with medically ill and injured homeless people who had just been discharged from the hospital. I accompanied them to their follow-up appointments, and seeing the kind of medical care they received and the way they were treated was really eye-opening and frustrating.

I spent a summer working with a bioethicist, and he told me I should go to med school. The problem was I had taken none of the requirements. 91´«Ã½ was a natural to think about: I loved the Tri-Co community, I loved the Philadelphia suburbs—I was sold. It was the only postbac program I applied to.

I lived above Cycles BiKyle on Lancaster Avenue, across from a noisy bar. My memory of the year is you studied constantly and then you took the MCAT. The faculty were terrific; I remember people like Alfonso Albano, who taught physics, and Maryellen Nerz-Storme—just amazing teachers. The other people I met in the postbac program were my first introduction to the culture of medicine and it was a group of people who were hardworking and ambitious and driven.

How did you get the idea for Progress Notes?

I married up; I married a 91´«Ã½ woman. We went to med school together, so every week I would see how much better she did on classwork than I did. My wife was meant to be a physician and loves being a physician. She’s also a family physician; in medicine there’s oftentimes a bias towards specialty care and away from family medicine care.

There’s a lot of talk within the field about how we’re not sending people into the right parts of medicine, and they often end up leaving the career early. Approximately 10 percent of physicians in the U.S. leave practice annually whether because of burnout, anxiety, or some of the frustrations of dealing with the American healthcare system. I became interested in telling a story about what works in medicine and in medical education.

I heard about this program at Denver Health, then I started to read about it and met with the person running it, Dr. Jennifer Adams, a general internist. She captivated me with her story about how you could reform medical education so that students would follow patients instead of physicians, and the two of us agreed I would spend some time looking at what her students did. Eventually, that became this book.

How is the training described in Progress Notes unusual, and what can it teach us about medicine and how it is taught?

In the 19^th century, there’s a series of reforms that tie medicine to the research university. The model for that is some of the research universities of Scotland, of Germany, and it’s codified in schools like Johns Hopkins and Columbia. There’s a great good of tying medical education to the research university: a commitment to science. There’s also some real harm, which is that medical education extended out longer and there are more barriers to entry.

Part of the problem is that we have a medical education model that moves further from the community and more towards the demands of the research university. Another part is embodied in the training where the key goal is for a very smart young person to take years off of their life and spend time doing serial apprenticeships in each of the core specialties of medicine. I call that a ‘textbook of the body’ approach, where you learn to relate to ill people based on their organs.

What I love about the LIC, or the longitudinal integrated clerkship model, is that it says: let’s take the good things about the textbook of the body — the rigor, the commitment to science, the technical skill—and let’s also add to it this relationship with the community and see if we can’t have students align with patients themselves. By going with patients and seeing what it’s like when they go to the emergency room, the urgent care clinic, the hospital and operating room, they are focusing on it from the patient’s perspective.

How does that reveal the pitfalls in the current model?

If you are advocating for change in medicine, the good news is that nobody thinks the current system is going great. If you ask the average American, they’ll tell you medical care is too costly, too difficult to access, and too complex.

The system shouldn’t be designed for healthcare professionals, it should be designed for the good of the patient. You need to work both on an individual and a structural level. This model has demonstrated an ability to train physicians that are more likely to work in primary care, more likely to work in underserved settings, and more likely to develop therapeutic relationships with their patients.

I began the book trying to write about something that works in medicine, because honestly, it’s so easy to write about all the things that don’t work. What I like about this is it’s a structural change that also builds up the individual people in it.

The medical students in the book learn a lot through the process, but did you gain any new insights from reporting their experience?

I learned a great deal. I remember that when I started my clinical training, I really thought about things on the side of the patients. I would think about how uncomfortable it looked to receive patient care. And by the end of the training, you start to think about the team and the team’s needs, and how you have to manipulate the body so you can do your procedures.

One of the things I talk about in the book is the way I would encounter patients on trauma surgery service. I would see them at their worst moment—out of an ambulance, with a knife in their chest or a gun wound—then I would see them displayed on an operating room table or in a hospital bed recovering.

The students I saw would see patients in that initial setting, but then would follow them for months later. They would even do home visits. They could really see them as a person over time. Trauma wasn’t just this inciting event—a car accident, a gunshot, a knife wound—but really something that spiraled out in complex ways through their life for months and years to come.

Did the Postbac program influence how you approach medicine?

I started med school when I was 25; I was considered a non-traditional student because I had gone out in the world a little bit, and I’m so grateful I had. The postbac program also gave me the confidence to learn a great deal of information quickly. But I’ll be honest, my favorite thing about my connection to 91´«Ã½ is the fact that I met the love of my life there, ultimately, and I don’t know that she would have given me the chance of a date if I hadn’t also gone to 91´«Ã½.

I went to the University of North Carolina for med school. There were a ton of people who knew each other, and I knew nobody. There was a young woman (Elin Kondrad ’99), and I just walked up to her at the first break on the first day of orientation, and I said, ‘I think I know you from somewhere.’ She told me that was a bad line. I asked her where she went to undergrad and she said, ‘I went to a women’s college, we don’t know each other.’

It turned out we had taken a physics class together, we had gone to a meeting with a free clinic together. We started hanging out and by Halloween we were dating. We got married as third-year med students, had our first kid during med school, and have been together ever since.

I’m grateful for my time at 91´«Ã½, for the chance to share this curriculum with people, and that 91´«Ã½ has run this postbac program for all these years to help people get into med school.

This interview has been condensed and edited for clarity.

Learn more about Progress Notes and Nussbaum’s other books at .