Why Asheville

Med students can't help but think ahead; it's in our DNA.  If you've known that you wanted to be a doc since the third grade, then you've thought about which high school would give you the best shot at getting into a top college, which would get you into a top medical school, to get you into a great residency, to get you working at a leading research institution, to get tenure, to get this and that, and so on and so forth.  I've started to realize that this can be a dangerous cycle.  The "I'll Be Happier Later in Life Model" leads to a very unhappy lifestyle in the present.  There is no endpoint; there is no final accomplishment that can make you happy.  It's falling in love with the process, even if in the moment that process frankly just blows.  When I am less than thrilled with the subject material, work, and didactic methods of the first two years of school, I fall out of love with the process.  Perhaps I only like the idea of being a physician.  But then I have an experience in the hospital, at EMS, or even in the classroom, that reminds me why I am here.  Appreciating those experiences is a key to the process, and they can turn a glass from half empty to half full.  I remember how lucky I am now, how lucky we all are, and it makes the process a little bit easier.

However, it's natural to look ahead.  The first question I am asked when I meet a new person is, "What kind of doctor do you want to be?"  That decision is one of the important milestones to keep in the back of one's head during the process.  Lately, I've been thinking a lot about my education next year.  Students at a state university have numerous geographic options for clerkships third year.  Each student works for 4-8 weeks in a different specialty: Surgery, Internal Medicine, Pediatrics, Psychiatry, Obstetrics and Gynecology, etc.  During these rotations, we learn in the hospital environment, developing clinical skills and knowledge in a block learning format.  UNC-SOM students can do these rotations in Chapel Hill, Wilmington, Raleigh, Charlotte, among other cities in North Carolina.  Twelve students, for example, will spend an entire year at Carolinas Medical Center (CMC) in Charlotte for their clerkships.  But, there is another option that has been piloted in the last few years: Asheville.

As stated earlier, traditional clerkships follow "block scheduling."  Each rotation is done separately, learning about a specialty in an intensive, focused manner.  Recently, however, a number of medical schools have experimented with an integrative third year program called "longitudinal learning," in which students essentially do all the rotations at the same time for an entire year.  As a highly simplified example, instead of being on the Cardiology service for 4 weeks, students follow patients with cardiac disease.  A patient with congestive heart failure may have other co-morbidities, such as diabetes, renal failure, perhaps a psychiatric illness, or upcoming surgeries, so the student is also involved in endocrine, renal, psychiatric, and surgical training as well.  This integrative model allows the student to work with patients from admission to the emergency room, to the inpatient setting, through follow-up visits in the outpatient clinic, and everything in between.  Students learn coordinated care, and work with an individual attending who guides them through their medical education.  Case-based learning, grand rounds, and individual study are incorporated into each week to ensure students learn the required material for national board examinations.

And the results?  Initial studies out of Harvard Medical School (see citation at the end) indicate that students do equally well on the standardized tests, and better on end of the year evaluations.  Although test scores are important, students also seem to retain a higher level of idealism, something that can be lost in the third year. "Students felt their year had better prepared them to be truly caring, to deal with ethical dilemmas, to see how the social context affects patients, to respond to patients of diverse backgrounds, and to involve patients in decision making" (Ogur, 400).  The model is not perfect, however, and there is only a small amount of data available.  But, a number of schools have piloted these programs and found similar success.  UNC will send 8 students to Asheville, NC next year in a pilot program that has been developed over the past few years.

Since thinking ahead is embedded in my chromosomes, I have come to realize over the past weeks and months that Asheville would be perfect for me.  It's not that there is anything wrong with sticking to traditional teaching; it's just that Asheville has several advantages for me specifically.  In no particular order, here is my "Why Asheville,"

1. Learning Style - I learn quick and forget quicker.  Although this has changed quite a bit as of late, with new study techniques and less procrastination, I now know I learn better when concepts are integrated.  I can retain information better, and can be much more efficient.  I worry that the block format, although intensive, may not be the best teaching style for me personally.  The idea of constantly reviewing and constantly integrating medicine in a longitudinal manner really speaks to me.  In addition, I would be able to work one-on-one with an attending with constant feedback and teaching.  I like that.
2. Future in Policy - At some point in my life, I see myself working on the state or national level in health policy.  In what capacity, whether as a county medical director or a Congressional staffer, I do not know; but if I want to work at the North Carolina state level, then I should have experience spending considerable time in different parts of NC.  I have been in Chapel Hill for almost 7 years now; it's time to see more than this liberal utopia.  Asheville sits in the western part of the state, with a much different local population and patient demographic.  And since I want to do my residency in a larger city, when else am I going to be able to train in a rural setting?
3. Innovation in Education - I talk a lot of smack, but I think it's hypocritical to complain without being ready for change.  This pilot program is a new way of looking at medical education, with promising early results.  If I'm not willing to be on the cusp of change in medical training, then I have no right to question the status quo.  I believe in this program, and I am passionate about making it mainstream.  Also, I hope to be a clinical educator myself at some point.  Innovations in education and one-on-one, more personalized experiences with outstanding educators can be the beginning to a career in teaching.  I would love to be on both sides of this coin.
4. ABC-H Rule - Like I said, I've been in Chapel Hill for going on 7 years.  Right now I'd like to be "Anywhere But Chapel Hill."  I think CH is a wonderful place for four years of college, and of course it is a fantastic place to come back to, but it's starting to get stale.  I've been going to the same bars, shopping at the same stores, and eating at the same restaurants, for seven years.  I've even lived in the same house for six.  I'm starting to get antsy, and I'm ready to go.  Who knows?  Maybe a year in Asheville and then a year in a half in Boston?

You always have to have a Plan B, and fortunately my other options are no slouch.  Adam Schauer has already promised me free rent at his house just 5 minutes from CMC in Charlotte, as long as I buy the groceries (Adam, I'm going to hold you to that one!).  I have a wonderful apartment here in Chapel Hill, and I can always do tons of away rotations across the state.  However, I think the Asheville pilot could benefit me, and I could benefit the Asheville pilot.  These are just four of the reasons Why Asheville; there are plenty more.  I shouldn't look ahead too much though.  Enjoy the here and now; enjoy the process.


Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007;82(4):397-404.