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  1. Angelique

    Angelique Thành viên quen thuộc

    Tham gia ngày:
    17/04/2001
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    Bring on the patients


    Students are exposed early to medicine's human face

    By Josh Fischman

    Steven Landers was prepared for the mornings in his first year of medical school. Afternoons, however, threw him for a loop at first. "Mornings were all lectures and labs," says Landers, a 25-year-old student at Case Western Reserve University School of Medicine in Cleveland. But about a month after school started, as part of an afternoon clinical education program, Landers was set up on a date-with an expectant mother. "I was supposed to go with her to prenatal care visits and be with her when she went into labor. I'd just gotten my little white coat-I was really nervous," he says. But Landers persevered and in the process of getting over his awkwardness, was reminded of why he had wanted to be a doctor in the first place.

    In a major departure from past practice, more and more medical schools are allowing students like Landers to learn from patients early in their education. Once hidden away from first- and second-year students, hands-on patient care is now part of their coursework from almost the first day of school. Some encounters with patients are intense: The University of New Mexico School of Medicine in Albuquerque sends students who have finished their first year to local family practice clinics for the summer. Others are less so: The University of Virginia in Charlottesville uses individuals who have been trained to recite specific clusters of symptoms to hone the diagnostic skills of first- and second-year students. The question facing med school applicants today isn't whether you want an early dose of patient care. It's how big you want that dose to be.

    Abstract is out. "We're moving away from teaching by abstract memorization," says Robert Eaglen, assistant secretary for the Liaison Committee on Medical Education, the curriculum guidance arm of the American Association of Medical Colleges in Washington, D.C. "We've found out it is pretty much useless for long-term learning." Students learn better, he says, when the biology described in a text-book is linked to the actual practice of medicine.

    That's a far cry from the tra***ional vision of medical school. For most of the last century, med students spent two years bent over textbooks. Medical school at the University of Chicago in the 1960s "was like being in this science-Berlitz monastery," says pediatrician Fitzhugh Mullan, who teaches at the George Washington University School of Medicine and Health Sciences in Washington, D.C. Only in the third year were he and his fellow students, "tumbled into the clinic."

    But by the late 1970's cracks began appearing in the wall between doctors-to-be and patients. One key reason was that students, sick of sitting in classes and labs from 8 a.m. to 5 p.m., began to demand change. In 1979, the University of New Mexico was one of the first schools to start what's called a "problem-based track." Students who signed up for it started-under the watchful eyes of a physician-to take medical histories and give basic physical exams. "We're in a rural area, and we had more call for physicians with general skills than for specialists who may not interact with patients as much," says Scott Obenshain, New Mexico's associate dean for undergraduate medical education.

    By the early 1990s, the University of Pennsylvania, Harvard, the University of California-San Francisco School of Medicine, the University of Wisconsin Medical School, and a host of others began to push patients in front of first- and second-year students. HMOs, which employ more primary care physicians than specialists, were growing in influence. And students all over realized clinical experience gave them an edge in HMO job interviews. "We do listen to what our students say," notes Donald Innes, associate dean for curriculum at the University of Virginia's medical school.

    While some schools simply offer students ad***ional opportunities to work with patients, many others created innovative curricula in which students get a mix of lectures and patient encounters in almost every class. This new approach attracted Drew Kalishman, 26 and a second-year student, to New Mexico, which merged its clinical track into its tra***ional schedule in 1993. "I wanted the science backed up by experience. Having a real face behind these medical problems is really helpful," he says.

    One of the many benefits of entwining experience with basic science is that it helps keep future doctors from getting buried by the avalanche of new medical information. "Our faculty was worried that students weren't making the connections they could be making," says the University of Virginia's Innes. So the school has begun to use "standardized patients" in a variety of courses. These people have been trained to complain of symptoms that are signs of certain illnesses. Students first learn to take medical histories on these "patients" and, later, to practice physical exams.

    Cool connections. Toby Campbell, 26, recalls meetings with standardized patients during his first year as a med students in Charlottesville. "It's pretty cool how it works. The patient [might] complain he goes to the bathroom a lot and has numbness in his feet. And from class, you remember that a high glucose level in the blood causes nerve inflammation, and it also makes the kidneys work overtime. High glucose can mean diabetes, so you've made a link to a real disease."

    Meeting patients-standardized or real-early in one's medical education also gives students more time to hone their bedside manner. Says Aalya Hassan, 24, another Virginia student: "The patients would give us feedback, like telling us if we did something to put them at ease, which is an important skill to learn."

    There's yet another career advantage in early patient encounters. They give students more time to figure out what field of medicine they want to move into. First-year-student Alexa Edwards, 22, says she chose University of Pennsylvania School of Medicine in Philadelphia partly because clinical rotations start in the second year and run through the summer. This schedule gives students many months of "trial runs" in specialty areas, she says, before they have to apply for residency programs in the middle of their third year.

    Despite students' eagerness to see patients, some schools are sticking with the more tra***ional model of medical education. At the University of Chicago Pritzker School of Medicine, for instance, the first year is still heavy on lectures and labs. "Our faculty are experts, and we teach beginning students about medicine on the cutting edge," says the dean of medical education, Lawrence Wood, adding that the first year provides students with the essential building blocks of a medical education. Jessica Carney, a 22-year-old first-year student, agrees. "You need to have the basic sciences down in order to do something good later. It might not seem interesting, but we can't help patients without it."

    But even Chicago is not the same school Fitzhugh Mullan described as a science monastery. Today, first-year students take a course called Introduction to Clinical medicine, and second-year students have extensive encounters with standardized patients. Carney works with the pediatric emergency room. "Formally there may be less opportunity for patient contact [than other med schools]. But really there's tons there," she says. "You can shadow clinicians if you want. The school runs free clinics and you can work there. It's just a matter of deciding what you want."



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