So Much to Learn, So Little Time
At Dallas’ Southwestern Medical School, one of the nation’s best research institutions, students not only have to master an exploding body of scientific knowledge—they also must learn to deal with social problems and a changing marketplace. No wonder becoming a doctor is harder than ever.
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Retreat From Flexner
THE NINE FIRST-YEAR STUDENTS WHO ARE GATHERED IN A SMALL, dimly lit conference room represent a small chink in the armor of Big Science, a recognition that biomedicine is not all that a prospective doctor needs to know. It is a departure from traditional first-year medical education—an intrusion of clinical practice into what previously was a pure academic regimen. Leslie Chin and her fellow students have been asked to fashion a full diagnosis and treatment plan for a fictional patient, Kerri, a thirteen-year-old African American female who is “feeling sick to my stomach, short of breath, and tired.” The patient has a medical history of insulin-dependent diabetes mellitus and has had ten hospitalizations over the past year for diabetic ketoacidosis (DKA), a life-threatening complication of the disease.
Even a layman could make an educated guess that Kerri has not been taking her insulin as instructed, leading to her frequent �are-ups of DKA. Remedy: Make her take her medication. Problem solved. But it’s not that elementary—which is the point of this four-year-old course called Introduction to Clinical Medicine. As it turns out, the case raises social, psychological, and ethical issues that these physicians of the future must consider along with the bioscience of her condition. To begin with, Kerri has two primary caregivers, her mother and her grandmother. Her mother feels that the solution is for the adults in Kerri’s life “to stand over her and make her take it.” The grandmother, the students are told, has a more laissez-faire attitude. The medical problem is really a social problem. The cutting edge of medical education today is not only science but also a recognition that the demands upon doctors have come full circle since Flexner issued his criticisms. In the future, as in the pre-Flexnerian past, doctors are going to have to be counselors, advocates, even sociologists to do their jobs.
The attack on the idea that science was the beginning and end of medical education began in the sixties, when there were calls for the medical establishment to come down out of its ivory towers and apply its knowledge and skills to urgent social problems ranging from crime to poverty. There were also complaints that the National Institutes of Health was spending too much money on arcane scientific investigation and not enough on practical, clinical applications. But the force of Big Science was too strong. Medical schools were responding to the explosion of knowledge by producing the specialists that patients wanted. By the late eighties the medical profession was crowded with specialists and short on generalists; the shortage became more acute with the arrival of managed care and its need for primary-care physicians.
The retreat from Flexner became evident in a 1989 article in the American Journal of Clinical Pathology by Harvard professors Robert Colvin and Miriam Wetzel. The authors argued that because of the new pressures on modern medicine, “development of skills, values, and attitudes should be emphasized at least to the same extent as factual knowledge.” The doctors went on to explain that the best way to address the twin burdens of exploding biomedical knowledge and a rapidly changing health-care-delivery marketplace was to get students out of the lecture halls and into problem-based learning seminars—like the one at Southwestern involving Kerri. There they could learn medicine by example, even during their so-called preclinical years, the first two years of medical school. The Harvard doctors concluded that only such a curriculum could foster the “self-directed learning” that doctors of the future must practice to survive.
The Introduction to Clinical Medicine course at Southwestern represents an admission on the part of medical academe that the managed-care revolution has reached into the ivory towers. (Indeed, the school has explored the idea of a course in the business of medicine—how to form a doctors’ group, bid on a managed-care contract, process Medicare paperwork, and obtain grant money.) Leslie Chin and the other students break down Kerri’s case into five areas: ethics, human behavior, preventive medicine, basic science, and clinical medicine. They will each research one area during the next week and report back with findings and recommendations. They also discuss the psychosocial aspects of the case in exhaustive detail: Should the physician’s course be to try to impose her will on the mother and grandmother or to cajole them into getting Kerri to take her insulin? Or can both caretakers be bypassed and Kerri persuaded to take her insulin more regularly? In any event, do all parties know enough about the disease and the medication to act responsibly on their own? The seminar’s two “facilitators”—doctors who are present only to nudge the deliberations in certain directions—ease the students through the various options, trying to get them to understand that it is not enough for a doctor to simply diagnose DKA caused by patient noncompliance.
A week later the students return, ready to decide on a treatment plan for the fictional patient. Leslie lays out the basic science of the disease thoroughly and succinctly—showing that biomedicine can be learned outside the lecture hall with the help of computers, textbooks, and a practical exercise. The students then decide that family counseling is necessary. Because the patient is a minor under the care of two legal guardians, the doctors must make certain that all three are completely informed of the nature of diabetes, particularly its long-range secondary pathologies such as blindness and heart, renal, and nervous-system degeneration. One student suggests that perhaps the young girl should be encouraged to attend a diabetes camp, where she would meet peers with the same af�iction and learn self-care; another recommends that the two guardians and the doctor devise a scheme of rewards for the girl for complying with the medication regimen. During the course of the conversation, subjects ranging from adolescent psychology to the family dynamics of inner-city African American families are discussed.
To the biomedical purist, such lengthy treks into the nonscientific territory of medicine by first-year students might seem like heresy. But the growth of such courses seems inevitable, even at Southwestern, which remains committed to bioscience first. The seminar proves that even first-year students can fashion a respectable diagnosis and treatment from scratch. And the exercise did teach the students to ask the right questions and where to look for the answers—in short, how to teach themselves. At a time when the basics of biomedical knowledge are almost incalculably large (it will have doubled by the time Leslie Chin and David Heise finish their residencies), these students need to know not only what they know but what they don’t know.
A Recurrent Headache
IN MID-NOVEMBER LESLIE CHIN FINALLY GETS her hands on a patient—not a real one, but a campus employee serving as a “dummy client” in a second clinical-medicine exercise. The charge to the students in this drill is to take a thorough case history from the “patient” based on a vague complaint—in this instance a recurrent headache. No professor is present; only six fellow students observe. Leslie’s performance will also be critiqued by the “patient” according to a lengthy checklist the school has given her. Later in the day, a professor will brief the students on potential testing and diagnoses that the case histories of their patients should have suggested to them.
For Leslie the exercise is a welcome break from the academic grind. In one five-day stretch in October, the first-year students had a three-hour biochemistry mid-term, a four-hour anatomy “walk around,” and an anatomy exam. Students studied ten to twelve hours a day. It was a humbling experience for Leslie. “I’m used to being among the best on every test,” she said afterward. “I did fine, but I wasn’t the best. It made me realize I’m competing with the best of the best here.”
Now she was meeting the middle-aged black woman who was her “patient.” After introducing herself, Leslie began to ask questions: What kind of pain is the headache? Sharp or throbbing? How frequently do the headaches occur? How long has she been having them? What prompted this particular visit?
The patient is good at what she does. Like a typical patient, she answers the questions tiredly, cryptically, incompletely. You can see Leslie’s mind racing to find the questions she might have forgotten to ask; among other things, the challenge here is not to let the patient leave without revealing everything germane to an intelligent diagnosis. Leslie asks about the patient’s work and family, the amount of stress they cause in her life. She inquires about her vision. Throughout, she scribbles furiously on a small pad.
Finally, she extracts from the patient that the most recent headache was accompanied by some numbness down one side of her body—a critical fact, since it might suggest a neurological disorder. Wrapping up, Leslie says as informally as possible, “That’s all I need for now. The nurse will be in presently … oh, my God, I forgot to summarize!”
Her fellow students chuckle. Leslie’s interviewing has been efficient and, for the most part, incisive and thorough. But in her nervousness, she has neglected to recapitulate the information to the patient, a crucial doublecheck of the symptomatology. She gathers herself and races through a summary, discovering along the way that she’d forgotten a couple of things the woman had said and misunderstood one symptom. “And you forgot to ask me about other symptoms,” the patient informs her during the critique. “I was ready to tell you I’ve been vomiting too, but you never asked.”
“This is harder than you’d think,” Leslie re�ects, as the students walk toward another room and another “patient,” this one complaining of a sore throat. “But I’ll know exactly how to do it the next time. It would have been easier if we didn’t have that biochem exam Monday hanging over our heads.”
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