New 'Doctoring' Course Steps Up Students' Hands-On Experience

by Wendy Y. Lawton

On a recent Thursday, first-year medical student Salma Faghri learned how to take a patient's blood pressure. Then, on a recent Tuesday, she got to practice - on real patients.

In the Cranston office of her faculty mentor, internist Jayson Carr, Faghri found out a few things she didn't cull from class. The bigger the blood pressure cuff, for example, the more you've got to pump. And when Faghri got a weak reading from one man, she watched Carr give it a try. To her relief, the doctor had a tough time, too.

"I love Tuesdays," Faghri said. "I get to apply what I learn. And I get to watch Dr. Carr work and see how he does procedures, takes a history, makes patients comfortable. The experience helps you see how it all fits together."

Faghri is enrolled in "Doctoring," a new two-year required course at Brown Medical School. In the course, first-year students spend one afternoon in the classroom each week learning medical interviewing and physical diagnosis from clinical and basic science faculty. Then they spend another half-day in the field, working alongside faculty mentors in their community practice, whether it's a private office, a public clinic or an emergency room. Students enrolled in the course also keep "field notes," journal-style entries on what they saw, what they did, and how they felt during their time with patients.

The point is to better bridge the gap between classroom and exam room and make the acquisition of clinical skills more active, more relevant, more reflective.

In previous years, Brown students didn't get face time with patients until their third and fourth year of medical school. But Arthur Frazzano, co-director of the "Doctoring" course, said that it makes sense, on several fronts, to start the interaction earlier.

"Students can practice what they learn, which reinforces what they learn," Frazzano said. "Students can also see that the basic science they get in class has practical applications. And when they enter clerkships in their third year, they're going to be better prepared."

The "Doctoring" course is a sign of things to come at Brown Medical School. Philip Gruppuso, associate dean for medical education, will oversee curriculum redesign in the months and years ahead. What students and faculty can expect: more active learning and more flexibility in students' courses of study.

Gruppuso said the addition of more group discussions, hands-on lessons and off-campus training makes sense given education research: Students who spend time doing - and thinking - learn more effectively than students listening passively to lectures.

The new curriculum will also incorporate scholarly areas of emphasis, such as ethics, aging, public policy or medical education. This means that students may spend some of their time with faculty mentors who are outside of medicine, such as ethicists, lawmakers or community activists.

"We want to make the curriculum more efficient and more responsive to students," he said. "We want to train intellectual physicians, people who can think critically, react quickly to new information, innovate. At the same time, we want to retain the Medical School's areas of excellence."

Updating the Medical School curriculum is in line with the Plan for Academic Enrichment. The process also squares with the Association of American Medical Colleges, which last year produced a report calling for changes in medical education that, among other things, give students early clinical experience and connect them with outstanding clinicians and teachers.

With the "Doctoring" course, Carr is impressed with the changes so far.

Being a faculty mentor, he said, has made him a better doctor. For example, having Faghri with him reminds him to speak in jargon-free terms with patients. Carr said his patients benefit another way: Thanks to her anatomy training, Faghri was able to explain all the muscles in the shoulder to a patient with tendonitis. "She remembers those a lot better than I do," Carr said with a laugh.

When Carr attended Brown Medical School - he graduated in 1995 - the only early contact he had with patients was in hospitals. The experience, he said, was limited. Most people were seriously ill, leaving little opportunity to talk.

"The earlier students get involved with patients, the better," he said. "It gets students to deal with people on a compassionate level right from the start. The experience can help them sort out career choices earlier. And it gets students, who are stuck in anatomy lab, a lot more excited about medicine. They can see how it's done."

Information Access - Stat!

Brown Medical School students are going digital.

This fall, for the first time, incoming students are required to buy and use a personal digital assistant, or PDA. These handheld devices - such as the Palm, BlackBerry and Treo - function as date book and Rolodex. They also allow users to connect to the Internet, access e-mail and run multimedia software.

At the Medical School, students plug information into their PDAs on patients they see through the new "Doctoring" course. A tracking system allows course directors to review these field notes and ensure that students get comparable clinical experiences.

Epocrates, a California company that creates PDA content for medical users, reports that thirty percent of U.S. medical schools, such as Duke and Harvard, require PDA use. The company also says that one in two medical students and practicing doctors use PDAs. Doctors - and doctors-in-training - can use them to access drug and disease references, track patients and lab tests, and calculate everything from drug dosages to cancer risks to infusion rates for anesthesia. - Wendy Y. Lawton