By Laura Ingles

While prepping a patient in the ICU for a liver transplant, Danny Walden, M.D., absorbed the details the patient shared with a visiting social worker about traumatic events in her past.

He immediately recalled a lesson from his days at the Virginia Commonwealth University School of Medicine and recognized what she divulged as adverse childhood experiences (ACEs), which can lead to substance abuse and other long-term health issues.

“When this patient told the social worker about all the terrible things that had happened in her childhood, I was very aware that it was those difficulties that led to her inability to cope, which led to her alcohol abuse, which was why she was being prepped for a liver transplant,” Walden said. “I thought back to that PPS lecture, and I knew I could help treat her liver disease, but in that moment it felt really inadequate.”

A growing desire to treat patients through the lens of prevention is what drove Walden to pursue primary care. He found specialties like emergency medicine and critical care frustrating because he felt unable to address the root causes of health issues.

“I want to make a difference in patients’ lives before they get to that point,” said Walden, who began his internal medicine residency in Rhode Island this summer. “It’s a lot easier to deal with someone’s heart failure than it is to deal with their homelessness. But we have to recognize these issues and their outsized impact if we want to have a generation of socioeconomically aware doctors who are able to combat diseases on multiple fronts.”

Students and faculty at the VCU School of Medicine, like Walden, as well as team members at the university-connected medical system VCU Health recognize that being a doctor is about more than diagnosing and treating illnesses. It’s also about connecting with patients, maintaining empathy and professional values in difficult situations and finding answers to complex questions. For VCU medical students, that’s where the Patient, Physician and Society (PPS) course comes in.

PPS is a course that is incorporated into all four years of the M.D. curriculum and covers topics like racial disparities in medicine, the impact of historical trauma on health outcomes, LGBTQIA+ health, medical ethics and empathy. Guest lecturers, case studies and small group discussions make the course engaging and collaborative, and the material is designed to push students out of their comfort zone and think critically about issues they won’t read about in textbooks but will encounter on clinical rotations.

“The overall goal is for students to see their patients as individuals,” said Kathleen Kreutzer, M.Ed., adjunct assistant professor and co-creator of PPS. “Every patient has something you need to overcome to build that good doctor-patient relationship. We hope that no matter what setting they’re in, our students will go on to really listen to patients and see them as partners in their health care.”

From the classroom to the clinic

According to Kreutzer, students used to receive some of this content through ad-hoc guest lecturers in a medical ethics class. About 10 years ago, as the School of Medicine was updating its curriculum, Kreutzer and a team of fellow educators — including the Department of Psychiatry’s Cheryl Al-Mateen, M.D., and James Levenson, M.D. — joined forces to streamline the lessons into an identifiable course. Kreutzer said that about 80% of the material has stayed the same over the years, but they intentionally designed the course to allow for flexibility and the introduction of new or topical subjects.

“We try to build on what they’re doing in other courses, and we talk about health disparities in every session, rather than making it a separate topic,” Kreutzer said. “We work hard to give students actual data and talk about the real effects on patients and their families.”

For example, when students learned that Black women in the U.S. are three times more likely to die from a pregnancy-related cause than white women, the information came directly from Charles Johnson, whose wife, Kira, died during the birth of their second son in 2016. Johnson is the founder of 4Kira4Moms, a nonprofit that aims to improve maternal outcomes through advocacy and education.

Meera Pahuja, M.D., an assistant professor in the Department of Internal Medicine, who’s led the PPS course since 2019, hopes that personalizing the issues will help students connect with them.

“They’re not necessarily going to remember the statistics,” Pahuja said. “But they’re going to remember the pictures of Kira and seeing those two boys now. They're going to remember that Kira was ignored, and that Charles felt like he couldn’t advocate for his wife.”

For student Mythili Vigneshwar, the first session that resonated with her was about breaking bad news to a family. The assignment was to role-play how she would reveal that a patient with cancer had died shortly after giving birth, and her mindset began to shift.

“I realized that I was going to be the one to have to deliver this news and be the support system for this family,” Vigneshwar said. “Even though there was nothing we could do medically in that case, it really hit me that this is kind of what this field is all about.”

Vigneshwar says it was important for her and her peers to recognize that while they worked hard to make it to medical school, they “worked hard to become doctors, not just to pass classes.” She began approaching her education with two different mindsets: “How do I ace this exam?” and “I’m going to be a doctor one day.” She tapped into the latter for the PPS course and continues to do so now that she has begun her clinical rotations.

“I started to realize that this is what I’m going to be applying as [a student] and beyond,” Vigneshwar said. “Sure, I can whip out the glycolysis pathway, but that’s not really what makes you a doctor and what makes patients trust you.”

Pahuja got involved with PPS around 2015 and co-leads it with the Department of Family Medicine’s Christine Paul, M.D. The course didn’t exist when she graduated from VCU School of Medicine in 2005, but she wishes it had.

“I would have had a framework to advocate for my patients on a much higher level, rather than anger and frustration and feeling like I wasn’t empowered to do anything,” Pahuja said. “The overall objective is about empowering our students. We’re empowering them to do something, to change our system, to make it better.”

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