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FEATURE


PITT'S RADICALLY REDESIGNED MEDICAL
CURRICULUM TEACHES STUDENTS TO THINK LIKE
PHYSICIANS BY GIVING THEM A HEALTHY DOSE OF REALITY.









THE BEST MEDICINE
WRITTEN BY LAURA SHEFLER
ILLUSTRATION BY ROXANA VILLA/SIS


"Is it all right if I look into your ears now?" Joe Suyama asks a small girl who sits, long-faced and droop-legged, in her mother's lap. Immobilized by shyness, the girl gives no response, but the mother nods consent. Suyama, a second-year Pitt medical student, steps forward to examine the child. Tenderly, yet tentatively, he brushes a few strands of blond hair out of the way. He gently holds her earlobe, then peers in through the black funnel of his otoscope. When he's done he steps back and asks her, "Did that hurt at all?"

Suyama is here as part of his course work at Pitt, shadowing pediatrician James Tucker in this office in Aspinwall, Pennsylvania. Tucker, of course, examines all the patients himself, but sometimes he asks the parents, as a favor, to let Suyama have a look first. The idea is to give Suyama a chance to get used to being alone with patients, asking them questions, talking with them, touching them.

An earache is what troubles this four-year-old girl today. The mother, who wears a down vest and keeps an arm wrapped around her daughter's middle, has told Suyama she's pretty sure that a sinus infection for which the girl has been taking antibiotics has now moved into her ears.

Suyama is trying, as best he can this early in his training, to gather clues about what's causing the earache. Unusual sensitivity to the otoscope could be a sign of an infection of the outer ear--as opposed to an infection behind the eardrum, or, perhaps, no infection at all. That's one reason why he wants to know whether his examination caused any pain. The young patient, however, keeps up her shy silence. The mother whispers his question to her again: "Did that hurt?"

Suyama adds a little coaxing: "I need you to help me out." In addition to wanting information about the cause of the earache, he wants to be sure he's handling the otoscope carefully enough. Furthermore, he wants the patient to feel comfortable talking to him. The girl curls the back of her hand against her face and softly answers that the otoscope didn't hurt: "No."

Cautiously, Suyama tells the mother, I saw something in there." Both he and she understand that Suyama is neither experienced nor knowledgeable enough yet to say for certain what that "something" means. Finishing up the examination, he asks the girl to open wide, and he looks into her throat. He feels for swelling in the glands under her chin. Then he says, "I'm going to go and tell Dr. Tucker exactly what I saw."

Five years ago, medical students at Joe Suyama's level spent most of their time attending lectures or getting ready for exams. They studied and worried and memorized their way through the year without ever meeting a patient. Rarely did they encounter the kinds of real-life questions physicians face. Now all that has changed, thanks to an innovative new curriculum at Pitt that has transformed the way students here learn medicine.

Until recent years, according to Steven Kanter, director of Pitt's Office of Medical Education, Pitt had a fairly traditional curriculum. Rote learning, Kanter explains, dominates the traditional approach to teaching medicine.

"Say I want you to learn the arteries in the neck. What I would have done is give you a big list--the carotid artery, the vertebral artery, and so on--and ask you to memorize it," he explains.

Only in the third year, when they began their rotations through clinical clerkships in the various specialities, such as psychiatry, anesthesiology, and surgery, did Pitt medical students gain hands-on experience. Says Kanter, "The word among students was that you got through the first two years and then you got to the good stuff."

In the late 1980s, however, the School of Medicine set out to see whether it could work more "good stuff"--more opportunities to learn by doing, to learn by working through problems--into the first two years.

Then-dean George Bernier assembled several task forces that involved both faculty and students. They studied curriculum reform at other medical schools--Harvard, for instance, which in the late '80s became one of the first American universities to introduce a radically new system of medical education.

Abandoning the lecture format, Harvard's New Pathways program arranged for students instead to learn together in problem-solving sessions. Drawing on such innovations, the Pitt task forces made suggestions for the medical school here. These suggestions led to the inauguration, in fall 1992, of a new curriculum called Physicians in Two Thousand or PITT.

Today, Pitt students still attend lectures, but they also spend much of their classroom time working in small groups. In these groups, they puzzle out solutions to written problems that mirror actual clinical situations. Students also take a series of thought-provoking courses on the relationship between doctor and patient, as well as visit outpatient health care sites, such as James Tucker's pediatric office. And, under the guidance of Pitt faculty members, med students work with patients in University of Pittsburgh Medical Center (UPMC) hospitals, learning how to perform physical examinations and elicit medical histories.

"This new curriculum makes the early years more interesting and more motivating," Kanter reports. By breaking with traditional methods of instruction, it seems, Pitt has broken with another tradition--that of the cheerless medical student.

"Our students are generally happy and satisfied," Kanter goes on. With the faintest gleam of humor, he adds, "That's somewhat weird in medical education."

BRIGHT AND EARLY ON A Monday morning, Joe Suyama and seven fellow students gather around a conference table on the fifth floor of Scaife Hall. (Ordinarily, there are nine in the class, but one student is absent today.

In the center of the table sits a bag of bagels. The students pass a crumpled coupon from hand to hand. "We finished it," someone says. This group has worked together through so many breakfasts--with each purchase noted on the coupon-that they are eligible for the next dozen bagels free.

Dressed in a white lab coat, Beth Piraino, the faculty facilitator for this "problem-based learning" session, passes around photocopies of the problem for the day. Piraino is the director for the renal section of a course on body fluid homeostasis. "Homeostasis" refers to the way body systems tend to compensate for illnesses and other disturbances to maintain stability. Piraino's role in this session is not to lead, but to answer questions and offer guidance as the students solve the problem. "I might step in once in a while," she confides, "to keep them from getting too far off track."

One of the students, Michelle Lightner, reads from the case description--not one from an actual patient, but based on cases that are fairly typical of the real-life problems doctors often see: "Arthur McBride is an 88-year-old man who is brought into the emergency room at the University of Pittsburgh Medical Center from the assisted living home where he lives with a two-day history of cramping abdominal pain, nausea, vomiting...." McBride has other symptoms as well, such as diarrhea, achiness, and loss of appetite. The case description lists the over-the-counter and prescription drugs he has been taking. It mentions that he has been urinating less frequently than usual over the past day or two.

"So is he hypovolemic?" asks Audrey Halpern, another student, who sits at the foot of the table. Diarrhea can cause hypovolemia, a condition in which a loss of fluid leads to a decrease in the volume of blood.

"Probably," someone says.

"Shall we write this or not?" asks Seth Holst, who has a close-trimmed beard and glasses. He answers his own question by going to the chalkboard and picking up a piece of chalk. "May be somewhat hypovolemic," he says aloud as he writes.

This is the way problem-based learning sessions typically work. The students decide informally who will read the problem, who will write down facts and hypotheses about the case. All participate in seeking a diagnosis. What's particularly challenging is that, before they can get to the answers, the students must define the questions. They must ask themselves what they need to investigate in order to treat the patient.

Clued in partly by the fact that this week's class deals with the renal system, the students turn their attention to the low urine output. They identify two likely causes. Either the patient's kidneys, whose job is to filter toxins from the bloodstream, are seeing less blood--a condition known as pre-renal failure--or else the patient has intrinsic renal failure, i.e., his kidneys are not working properly.

A discussion about these two possibilities at first yields little clarity. At one point, when the group has been talking about what might have caused renal failure in the patient, Halpern asks, "Are you saying that we've progressed from pre-renal to renal?" Suyama says, "It's just a hypothesis." He adds, "We need to see his blood."

Before taking a blood test, however, a real physician would perform a physical. Suyama turns to Piraino and says, "We want to see his vitals and stuff."

Piraino hands around a second sheet, the results of a physical examination. "Holy moly, look at his pulse!" exclaims Heather Jerald, who sits across from Suyama.

What she has noticed is that the pulse rises from 90 beats a minute when the patient is lying down to 132 beats a minute when he stands. That dramatic rise in pulse rate, which accompanies a drop in blood pressure, is probably a sign of low blood volume. The heart is trying to compensate for a loss of blood to the upper body and the brain as the patient stands.

"He's definitely hypovolemic," Suyama says.

Other vital signs, such as dry mucus membranes, flat neck veins, and a lack of sweat under the arms, confirm that the patient is low on fluids. When the students ask for a urine sample for analysis, McBride proves unable to urinate and must be catheterized--further indication that something is going wrong with his kidneys.

The results of the blood test and urinalysis, for which Piraino has handouts ready, prove less immediately accessible. The students look up figures in their course handbooks, converting deciliters to liters and debating whether the patient's sodium, potassium, and creatinine (a by-product of muscle activity) are higher or lower than normal. "His urine is very concentrated, with low sodium," Halpern concludes. "Is that pre-renal?" she asks.

Ultimately, Piraino does step in, asking, "What can you do with the urine creatinine and sodium, and the serum"--i.e., blood--"creatinine and sodium, to make sense out of what's happening?" Thus reminded, the students recall equations they learned in lecture. These equations compare creatinine and sodium levels in blood and in urine to determine how well the kidneys are filtering. Piraino goes to the chalkboard and leads them through the calculations. Audrey Halpern looks at the results and says, "He is definitely pre-renal."

"Good call, Audrey," says Seth Holst. The ratios that the equations have yielded indicate a pre-renal state. The main goal now, the students agree, is to raise the patient's fluid level to get more blood to the kidneys. They put him on intravenous fluids, noting that an actual physician would also investigate the underlying causes of the illness.

Piraino passes out a final photocopied sheet that says that after a few days on fluids, the patient is doing better. "Is that it?" someone asks. "We win!" a couple of people say at once. There's laughter, and then someone asks, "Which stuffed animal do we get?"

After a moment, though, the students are back to business, divvying up the "learning objectives" they will research for discussion on Wednesday. One student, for instance, will read up on pre-renal failure, while another will investigate intrinsic renal failure. Someone else will report on lisinopril, a drug the patient has been taking for high blood pressure. The missing ninth student gets an assignment in absentia: "He can pick up the bagels," the others say.

Time-consuming and intense, problem-based learning sessions may not seem, at first, like the most efficient way to learn medicine, but Steve Kanter of medical education insists that they are an especially effective teaching tool. "We think the students learn the material better because they learn it in context," he says. While memorization may fade after the exam, people tend to remember vividly the things they have learned by experience. "Physicians can often remember details about a patient they saw 10 or 15 years ago," Kanter points out.

Joe Suyama will tell you that he uses the problem-based learning sessions, or PBLs, to test his own knowledge of material. In the PBLs, he says to himself, "'I've sat through 12 lectures. What did I retain?'" It's invaluable, he adds, to take equations he has learned in lecture and apply them in the PBL. "I see it, and I say, 'Okay, that makes a lot of sense.' It's a good way to drive points home."

Kanter adds that the science of medicine is advancing so quickly that much of the information students memorize in their first year will be outdated by the time they graduate. PITT, therefore, emphasizes not just factual knowledge, but also critical thinking skills. "We want the student to learn how to access evidence that pertains to a particular case. We want them to be lifelong, self-directed learners."

Yet even when it comes to factual knowledge, the PITT curriculum has fared well. Some medical schools that have adopted problem-based curricula have seen a drop in scores on the National Medical Board of Examiners test, which students must pass in order to become physicians. At Pitt, however, classes educated under the new curriculum have done as well on the boards or better than previous classes. Pitt's scores have remained above the national average, both for the test overall and for each individual subject area on the test.

Applications to Pitt have seen increases, too. In 1993, they went up at about twice the rate that national applications have increased, and in 1994 they increased at more than two times the national rate. "Admissions are very competitive, and we pick from the top," Kanter says.

Jenny Driver, a third-year student, applied here because of the new curriculum. As an undergraduate, Driver had majored in South Asian Studies at Brown University. "What attracted me to medicine is taking care of people," says Driver, who has done well in her basic science courses even though she is not the typical, science-oriented medical student. "To me, a curriculum that focused on the technical side, excluding all other aspects of medicine, would have been painful. I was looking for something a little more holistic and where I could really use my brain.

"One highlight was that, rather than starting with anatomy, as they do in many schools--jumping right into the science-we started with a course called Introduction to Being a Physician and with patient interviewing. This set the stage for taking care of the person and put things into the context of the bigger picture." The focus on the patient enriched even the most technical aspect of the first two years. "Sometimes," Driver adds, "they would bring patients with diseases we were studying on a molecular level into the lecture hall and they would tell us, 'This is what it's like to have cystic fibrosis,' or 'This is what it's like to have a heart transplant.'

"It's an interesting time to be a medical student," she says, "because so many things are changing. Even our professors don't know what medicine's going to look like in one or five or 10 years." What she's talking about, mainly, are changes in how health care is financed and delivered. She suspects, for instance, that most people in her graduating class will wind up working in some form of managed care.

Uncertainty about the future means that more than ever physicians must be adaptable. They must balance complex social pressures--such as growing incentives to keep costs down--with the imperative to act in the patient's best interests. That's one reason that medical students need a mature and broad perspective on the work physicians do.

The PITT curriculum encourages students to see the physician's role within a larger framework. For example, the course on epidemiology--that is, the study of how diseases affect large populations--uses epidemiological research to address questions about how physicians serve their patients: Should doctors routinely screen for widespread diseases such as prostate cancer? How should they weigh the risks and benefits of new surgical treatments?

Medical ethics courses at Pitt tackle even more complicated issues. Take, for instance, a recent afternoon class session exploring questions about "advance directives" such as living wills. A man with terminal lung cancer appears in front of a large group of second-year students. At his side sits his wife, whom he has designated as a legal surrogate to make decisions for him if he's unable to communicate. Paul Rogers, Pitt's associate director of critical care medicine education, interviews this patient, who has directed that he does not want to have his life prolonged by artificial measures.

One of the fine points that Rogers wants to get across is that even where there's a living will, physicians must talk with their patients, if possible, before there's a crisis, in order to understand what they want. Under Pennsylvania law, a doctor who knowingly violates a patient's wish not to be put on life support could theoretically be charged with battery.

Rogers insists, however, that many patients who have asked not to be resuscitated would accept life support under some circumstances. Rogers asks the patient: If you were having a seizure that was not caused by your lung cancer, and if the doctor could return you to the state of health you had before the seizure, then would you allow yourself to be put on a breathing machine?

"That," affirms the patient, "is a different situation altogether."

After the lecture, the second-year class breaks up into small groups. Back on the fifth floor of Scaife Hall, Joe Suyama and the other students in his group discuss the issues raised in lecture. They toss around ideas for educating people-especially young people, who might not otherwise give the matter much thought-about how to write clear advance directives. "Living will day at the mall," Suyama suggests, mostly, but not entirely, joking.

The students raise a myriad of questions for their faculty facilitator, John Kreit. Whom should the doctor trust-in the absence of clear instructions-to make decisions as the patient's surrogate? An estranged family member, for instance, rather than a live-in girlfriend? (The surrogate, Kreit asserts, should be not necessarily the next of kin, but rather the person who knows the most about the patient's wishes.) Do you have to be at least 18 to make a living will? (Yes.) Can a patient's children override the parent's advance directive? (No, patients have a right to make their own decisions.)

One essential belief that drives the Pitt curriculum is that Pitt students gain a deeper understanding of the work of physicians by meeting with patients one-on-one. Two separate courses give first- and second-year students direct contact with patients. One is Ambulatory Care, the course that brings Joe Suyama to James Tucker's pediatrician's office one afternoon a week. Not every student gets to examine patients as Suyama does, but each one does get to trail a physician and see firsthand what doctors do.

The course lasts from January of the first year until December of the second. The idea is for students to spend time out in the community--in places such as physicians' offices, neighborhood health clinics, physical rehabilitation centers, or hospital emergency departments. More and more often, it is at these sites, and not in hospital beds, that patients receive their health care.

Suyama describes his ambulatory care visits as a welcome break from his regular schedule. Yet clearly he works hard and thinks hard even here. Between patients, Suyama and Tucker frequently confer in Tucker's office, where the diplomas on the wall have been papered over with crayon drawings by Tucker's sons. Suyama and Tucker discuss a broad range of topics: how to test someone's eyes for strabismus, which medicines taste best to children, how to get a baby to stop crying long enough to listen to its heart. When Suyama has looked at a patient, Tucker often pushes him to venture a diagnosis.

"The ears are infected, I think," Suyama says about a second child that he had examined that day.

"If you're wrong, it doesn't matter," Tucker says, pushing him.

Suyama makes a commitment: Yes, the ears are infected, and the child has a throat ailment as well. "So is this viral or bacterial?" Tucker asks.

Suyama hedges. "It's kind of tough...."

"You're absolutely right," Tucker says. "No one can tell." A slight exaggeration, it turns out: When he looks at the girl himself, Tucker notices small ulcers on her throat that suggest that she has a virus. But he tells Suyama, "The ear looks exactly the way you described it. You did it. Absolutely."

The other Pitt course that brings students together with patients is known as Clinical Skills. The clinical skills course takes place at UPMC hospitals, where the students work with patients who are often seriously ill.

The student's task is to get the patient talking, to learn the person's medical history. In the first semester, the students practice medical interviewing techniques with actors who "simulate" patients. The clinical skills course that follows is still just practice: The hospital doctors already know the patient's medical history. Still, the students get the chance to take the skills that they have learned and try them in the real world.

Robert Thompson is a second-year student who came to Pitt without special expectations of the new curriculum. When he visited campus for his admissions interviews, he learned a little about Physicians in Two Thousand. "I was rather impressed," he recalls, "but it wasn't that big of a deal."

One thing that has surprised him has been the personal impact of seeing patients. "I'm a non-traditional student," says Thompson, who worked for several years after graduating from college. "I went and got some life under my belt before I started here. What I have learned is that even though I'm a little older than some students, my viewpoints are not carved in stone. This place changes your perspective."

When he is asked how his views have changed, he hesitates a moment. "You see a lot of sick people," he answers simply, then adds that he notices more keenly now when he or his friends start complaining about comparatively "mild things."

It's a quiet and straightforward observation that Thompson is making: that many patients suffer greatly, enduring more than most people ever expect to bear. It is an observation that has taken root early with Thompson. An observation that a student in a traditional medical program might not yet have had the chance to make.

At the heart of the PITT curriculum is the kind of physician the school wants to produce: analytic and reflective. Able to work together in team relationships with their colleagues. Attuned to patients and their needs.

Pitt's new way of teaching reveals a profound respect on the part of the school for the students who come here--a solid optimism about their capacity for compassion and growth and change. In the end, there is no physician who is perfect, no physician who knows everything, no physician who can foresee every turn a patient's health might take.

Still, if all goes well, the graduates of Pitt's medical school will go out into the world well prepared for the uncertainties they'll be facing, intellectually and emotionally ready to do their thinking on their feet.


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