Strong Medicine

Sumit Shah is focused on the patient’s face as he palpates her abnormally large spleen. The 48-year-old woman is scheduled to undergo a splenectomy in the morning to relieve the pressure on her diaphragm. Meanwhile, Shah and eight other first-year medical students have pulled on latex gloves and trooped into her room at Stanford Hospital to press their fingertips on her abdomen. Gingerly.

In the nine months since he started at the School of Medicine, Shah has learned about pacemakers and Swan-Ganz catheters, cardiac bypass surgery and pharmacological interventions. He also is picking up clinical skills early in his first year, using Wednesday, when no core courses are scheduled, to take an elective called Physical Findings Rounds. “I brought a friend from Cornell Medical School [on rounds] last week and he was astonished that we were seeing real patients,” Shah says. “He was pretty amazed that we were getting this clinical exposure.”

Shah’s class is at the forefront of what Philip Pizzo, dean of the School of Medicine, calls “one of the fundamental changes happening in medical schools across the nation.” Since the 1990s, deans and faculties at the 125 medical schools in the United States have been revising their curricula in an effort to graduate doctors whose clinical skills and bedside manner are as up-to-date as their knowledge of basic science and medical technology. At Stanford’s small, research-intensive medical school, which aims to turn out an equal number of clinicians and academics, the dean has overseen a “re-blending” of preclinical and clinical study.

Traditionally, medical students spent their first two years—the ) ) ) ) ) preclinical years—learning about cells, tissues, genetics and ) ) ) ) ) other building blocks of medicine. In the spring of ) ) ) ) ) their second year, they would get a crash course in ) ) ) ) ) clinical skills, then spend the next two years in several-week ) ) ) ) ) rotations in hospitals, getting a feel for specialties like surgery, ) ) ) ) ) pediatrics and psychiatry. But for the past three years, Stanford ) ) ) ) ) students have begun learning clinical skills, along with basic science, ) ) ) ) ) from the first day of class. In Practice of Medicine (PoM), a new, ) ) ) ) ) required, six-quarter course, they learn communication skills; and ) ) ) ) ) experienced doctors show them how to perform physical exams and take ) ) ) ) ) medical histories. “It ) ) ) ) ) really teaches us the humanization of medicine—that we’re ) ) ) ) ) not just gatekeepers of drugs, but that we’re actually caring ) ) ) ) ) for patients and being good listeners, and that that’s a big ) ) ) ) ) part of medicine,” Shah ) ) ) ) ) says.

In the past, self-directed medical students could take electives and do research on topics that interested them. But under the new curriculum, all students must select one of 12 “scholarly concentrations,” or majors, and take specific courses to fulfill its requirements. Pizzo is especially keen on this curricular change. As a pediatrician who has researched new approaches to childhood cancer for 30 years, he praises focused study in a specific field: “I know that deeply engaged analytic thinking permits one to be a much better reader and practitioner of evolving medical practices.”

Pizzo pushed for a new curriculum because, he says, “medicine ) ) ) ) ) has become more technological, [and] that has erected ) ) ) ) ) a barrier between clinician and patient.” It’s easy to ) ) ) ) ) rely on diagnostic tools such as CT scans, but Pizzo ) ) ) ) ) counsels that “the ) ) ) ) ) laying on of hands and touching and contact are critically ) ) ) ) ) important.” He ) ) ) ) ) adds that “engaging the public trust requires that the medical ) ) ) ) ) profession rewrite itself,” and says that effort is “where ) ) ) ) ) the interplay between compassion and science becomes ) ) ) ) ) so important.”

All of which explains why Shah, who is only months along a four- or seven- or even 11-year course to becoming a doctor (depending on the specialty he chooses), is interacting not just with mannequins but with actual, ailing patients. As a member of the third class to enter medical school under the new curriculum, Shah started classes three weeks earlier than his predecessors, and he likely will begin his clinical rotations a month or two before they did. Under a long-standing pass/fail policy at the medical school, he will not receive letter grades (a written evaluation is sent to residency programs in lieu of a transcript). Shah is glad that policy was preserved, and appreciates the cooperative spirit it fosters. “We all send out review notes, especially around finals, and someone recently sent an e-mail saying, ‘I have a master’s in epidemiology, if anyone needs any help,’” he says.

Neil Gesundheit, an associate professor ) ) ) ) ) of medicine who serves as associate dean for advising and director ) ) ) ) ) of preclerkship education, gives some credit to serendipity as he ) ) ) ) ) recalls the discussions that led to the new curriculum. “It ) ) ) ) ) was almost like a meeting of celestial bodies that you have in an ) ) ) ) ) eclipse of the sun,” he says. “In the fall of a second ) ) ) ) ) year, by coincidence, we happened to [teach] pulmonary pathology, ) ) ) ) ) pulmonary physiology and the pharmacology of drugs that work on the ) ) ) ) ) lungs. And students said to us, ‘When that happens, it is so ) ) ) ) ) fantastic because you can really connect all three. Why can’t ) ) ) ) ) we have a curriculum where it happens by design?’”

Such connections are at the heart of the new, integrated coursework that aims to teach medicine by studying complete organ systems, one by one. In the past, medical students learned about basic sciences like physiology or immunology as stand-alone disciplines. Now, in the new three-quarter course Human Health & Disease, they study such subjects as they relate to each of the body’s organs. Take the heart. First, students look at histology of the heart, or the appearance of normal heart tissue under a microscope. Then comes the physiology of the heart—how it works. Also pathology—what happens in diseases of the heart. And pharmacology—the effect of drugs on the heart. In other words, they learn the “phys, path and pharm,” as they call it, of every organ system, from lung and heart to brain and kidney.

“The first year is a lot of foundation material, and in the second year we go through all of these disease system blocks,” says second-year student Matt Craven. “We learn about how a big disease like diabetes works, including how you treat it and how to look after patients who have it. That’s what I came for, to learn how to do all these things.”

There likely is no typical student among the 86 who enter the MD ) ) ) ) ) program each fall, but the British-born Craven, ’01, exemplifies ) ) ) ) ) the idealism and altruism that many bring to their ) ) ) ) ) studies. After majoring in economics, he spent several ) ) ) ) ) years in Tanzania, working on HIV/AIDS education projects ) ) ) ) ) and forming Students for International Change, a nonprofit ) ) ) ) ) organization that sends some 40 students to work in ) ) ) ) ) Tanzania every year. Craven hopes to specialize in ) ) ) ) ) infectious diseases, perhaps with an organization like ) ) ) ) ) Médecins ) ) ) ) ) Sans Frontières ) ) ) ) ) (Doctors Without Borders). Until then, some of his ) ) ) ) ) extra energy is siphoned into ultimate Frisbee with ) ) ) ) ) the intramural team Slipped Discs, but most of it is ) ) ) ) ) devoted to being a teaching assistant for the first ) ) ) ) ) three quarters of PoM.

Three white-coated, stethoscope-toting, ) ) ) ) ) first-year students are huddled together in a corner ) ) ) ) ) of Fleishmann Labs during a recent PoM class. One is ) ) ) ) ) playing the role of the patient, the second is the ) ) ) ) ) physician who is interviewing her and the third student is an observer ) ) ) ) ) who is watching to see how the doctor-patient relationship is launched ) ) ) ) ) in the critical first minutes of their appointment. Patient complains, ) ) ) ) ) dramatically, about chest pain and a cough that has brought up blood. ) ) ) ) ) Doctor asks, sympathetically, when the cough started and what makes ) ) ) ) ) it worse. Observer notes that the visit is going pretty well. “You ) ) ) ) ) let silence work,” Observer ) ) ) ) ) says to Doctor. “You waited for her to expound.”

“Maybe my questions were too specific?” Doctor wants to know.

“No, you were great,” Patient says. “You cared about me.”

Clarence Braddock, the real doctor who directs PoM, is visibly pleased with the students’ communication skills, which are the topic of the day. Five or 10 years ago, he says, medical students would not have had contact with real patients until midway through their second year. Now, they are learning how to take medical histories with attention to cultural differences among patients and how to do rudimentary physical exams in the first quarter. They start out practicing on one another, and move on to working with professional actors who are trained to present headaches and sore knees as “standardized patients.” By spring quarter, they are doing physical exams on real patients at Stanford Hospital, with observers standing by in the same room. “You can’t talk to people about a physical exam—they have to do it, and be observed, and get very specific feedback,” says Braddock, ’77, an associate professor of medicine.

“Inspection, palpation, percussion, aus­cultation,” first-year student Elena Garcia says, ticking off the physical exam skills she’s learned. Then come exams on “student educators” who guide first-years through some, shall we say, daunting procedures. “It was a full prostate and rectal exam,” Garcia says about the first male pelvic exam she performed. “I was very nervous about it, but talking [with the student educator] made it a lot easier to do, in the context of, ‘This is an educational experience, a clinical, professional thing.’ It’s another initiation step.”

The classic initiation to medical school is anatomy class, where groups of students learn about the human body by dissecting a cadaver. “In the first session, we tell them how the bodies are donated, and that the previous occupants wanted to do this, which I think helps a lot of them,” says Ian Whitmore, professor of anatomy in the department of surgery. “If they all do a bit of dissecting on the first day, that tends to get them over potential problem areas.”

Julie Parsonnet, senior associate dean for medical education and student affairs and a professor of infectious diseases, calls anatomy “an incredibly popular course” that is “considered such a rite of passage.” It, too, has been integrated into the new curriculum. Faculty have restructured the course so that a portion of it is taught in winter quarter rather than the traditional autumn. Students are dissecting the heads and necks of their cadavers at about the same time that they’re studying the central nervous system and seeing patients with cranial nerve defects. It’s all about synergy.

Stanford isn’t the only medical school that employs an organ-system curriculum; Case Western Reserve, for example, has been using one for decades. Nor is this the first time Stanford has tried it. In 1959, University President J.E. Wallace Sterling oversaw a major curricular overhaul that organized courses around organ systems. It lasted less than a decade: in 1968 the faculty did away with required core courses in favor of an all-elective curriculum. By the mid-1970s, the School of Medicine had returned to the traditional model of two years of basic sciences followed by two of clinical rotations.

For the past 15 years, faculty across the nation have been searching for ways to keep medical education in step with discoveries in molecular medicine and with challenges posed by the burdened American health care system. “It’s a very robust national dialogue,” says Helen Loeser, associate dean for curricular affairs at UC-San Francisco. “In every school there is a different landscape and different chemistries, so to speak, so we all arrive at different solutions.”

The most distinguishing feature of Stanford’s new curriculum is its scholarly concentration requirement. A task force of the Association of American Medical Colleges in 1994 identified “the central importance of an environment of discovery to the core mission of medical schools,” and a number of institutions are now looking to the model that is evolving on the Farm. Ron Drusin, interim senior associate dean for education at Columbia University’s College of Physicians and Surgeons, says scholarly concentrations “are an innovative addition to medical education that sets the stage for providing students with ongoing skills in curiosity and lifelong learning.”

The concentrations range from bioengineering to biomedical informatics to women’s health to community health and public service. There’s also the option to design one’s own concentration. Within each, students may opt to pursue more coursework (the “scholars track”) or more independent investigation (the “original research track”). “Nationally, there’s a lot of dissatisfaction with medicine,” Parsonnet says. “You hear people say, ‘I wouldn’t do it again—go into medicine.’ But our sense is that medicine is fun because intellectually it’s a wonderful field. And what we’re trying to do is tell people that a career [in medicine] will be much more exciting if you have the skills and knowledge to dive into something, that it’s about engagement and excitement and intellectual involvement.”

First-year Brooke Lane gave up a scholarship to an MD/PhD program ) ) ) ) ) at the University of Alabama to attend Stanford because ) ) ) ) ) research was her top priority. Like a number of students ) ) ) ) ) in her class (seven have PhDs and eight hold master’s degrees), ) ) ) ) ) Lane has completed postgraduate training: two years ) ) ) ) ) of graduate research in microbiology at Washington ) ) ) ) ) University in St. Louis. In winter quarter she contacted ) ) ) ) ) Manuel Amieva, MD/PhD ’97, ) ) ) ) ) assistant professor of pediatrics and of microbiology ) ) ) ) ) and immunology, to ask if she could work in his lab. ) ) ) ) ) Lane is now conducting an experiment with epithelial ) ) ) ) ) cells, infecting them in vitro with Helicobacter pylori, ) ) ) ) ) a bacteria that’s associated ) ) ) ) ) with stomach cancer.

Given that singular focus, Lane plans to select molecular basis of medicine as her scholarly concentration. “I feel like the lab is the best outlet for me to be innovative, and to be able to use my creativity to improve medicine and our knowledge about the basic sciences.”

Parsonnet says the effect of the new focus on research is evident in the number of grants students are being awarded—double the number their predecessors brought in—and in the number of Howard Hughes Medical Institute Fellowships they are winning. This year 13 Stanford students received Howard Hughes awards, more than at any other university.

Confidence in the new curriculum overall has been bolstered by the scores that Stanford students are earning on Step 1 of the United States Medical Licensing Examination, a daylong test they typically take in the late spring or early summer of their second year. “When you revise your curriculum, it’s not uncommon that scores fall in the year after you’ve revised,” Gesundheit says. “We didn’t know what to expect, and we were just thrilled.” Four years ago, the mean score for Stanford students was 230 out of a possible 280. The mean score of the first class that studied the new curriculum was 237, and 50 percent scored above the 90th percentile.

Every spring, the second-years undertake marathon study sessions ) ) ) ) ) to prepare for the USMLE. “It’s definitely something that ) ) ) ) ) has weighed on me since the beginning of this year,” says second-year ) ) ) ) ) student Adeoti Oshinowo. “It’s the gorilla on your back; ) ) ) ) ) it’s seven blocks of questions about everything we’ve ) ) ) ) ) learned in two years.” The month of May looks like a patchwork ) ) ) ) ) quilt on Oshinowo’s laptop: on light blue days she reviews the ) ) ) ) ) respiratory system, on green days it’s cardiovascular physiology. ) ) ) ) ) The day after the exam, she heads home to Illinois, ) ) ) ) ) briefly, to visit with her family, then flies on to ) ) ) ) ) Nigeria, to start a research project on postpartum ) ) ) ) ) hemorrhaging.

A collegiate discus thrower (whose brother, Babatunde, ’05, ) ) ) ) ) played nose tackle for the Cardinal), Oshinowo tutors ) ) ) ) ) undergraduate student-athletes in organic chemistry. She finds time ) ) ) ) ) to serve as vice president of the Stanford Medical Student Association, ) ) ) ) ) and helped organize the annual “Moonlighting” dance last ) ) ) ) ) fall. This fall, she’ll be stopping out for a year to earn a ) ) ) ) ) master’s ) ) ) ) ) degree in public health at the University of California-Berkeley. “I’m ) ) ) ) ) so excited to be able to be in a position where I can ) ) ) ) ) really, really help people, and to be able to help communities be ) ) ) ) ) empowered about their health care.” Taking five years to earn ) ) ) ) ) an MD is becoming commonplace among Stanford students—whether ) ) ) ) ) it’s because ) ) ) ) ) they’re conducting research projects or pursuing a second degree ) ) ) ) ) in a related field, as Oshinowo is doing.

Nearly half—46 percent—of Oshinowo’s class are women, and 23 percent, like her, are from minority groups that are underrepresented in the medical profession. She has wanted to be a doctor since she was 3—“well, my mother tells me there was always a variation, like I wanted to be a doctor and a lawyer, or a doctor and an opera singer”—and she now has her sights set on a career in obstetrics or gynecology.

Oshinowo recently was paired up with an expectant mother in the elective class Mommies and Babies, and not only accompanied the woman to all of her prenatal appointments, but also held her feet as her baby was born. “It was beautifully terrifying,” Oshinowo recalls. “Beautiful because life was coming into the world, and terrifying because I want to have one of those one day.”

Experiences like these make Oshinowo ) ) ) ) ) and her counterparts well prepared for their clinical years. Among ) ) ) ) ) those who have gone through the new curriculum, “I’ve ) ) ) ) ) seen, as have others, a difference in the overall level of preparedness, ) ) ) ) ) both in a knowledge base and a skills base,” says associate ) ) ) ) ) professor Sherry Wren, who has directed the required rotation in surgery ) ) ) ) ) since 2000. “They’ve clearly interviewed patients before, ) ) ) ) ) they’ve done physicals and they also seem to be more comfortable ) ) ) ) ) on the wards.”

Wren, who graduated from Loyola University’s Stritch School of Medicine, contrasts that preparation with her own some 20 years ago—when she didn’t take a physical diagnosis course until the final month of her second year, and didn’t see a patient until she started her first clinical rotation. “The old-fashioned medical education was, ‘We’re just going to throw you in and see how you fare.’ Now they’re getting a structured educational approach, and we really are teaching people how to do things before letting them jump in.”

On a recent morning, third-year student Prasanna Ananth is making bedside rounds as part of her rotation in adult intensive care at the Veterans Administration Hospital in Palo Alto. Because the patients she sees in the intensive care unit are sedated and intubated, Ananth, ’02, spends most of her time checking ventilators and getting updates from nurses on the ward. When she goes on rounds, she travels in a white-coated flock of a dozen interns, residents and fellows. Ananth waits at the bottom of the pecking order, hoping to perform any procedure the others aren’t interested in doing. Unlike first-year students, who mostly observe on rounds, Ananth has to know every patient’s history and be ready for unexpected questions.

“So, Prasanna, tell us: what does milrinone do?” the attending physician asks suddenly. She hesitates, and then responds with a mostly correct reply. “We call it being pimped,” she says later about the on-the-spot questioning. “It can be embarrassing when you don’t know the answer, but at the same time, you’ll never forget it again.” Milrinone, incidentally, is an intravenous, short-term therapy designed to make a diseased heart beat stronger.

Ananth and her classmates were the guinea pigs—the first students ) ) ) ) ) to start medical school under the new curriculum. In ) ) ) ) ) her first clinical year, she’s seen patients at several local ) ) ) ) ) facilities—Lucile ) ) ) ) ) Packard Children’s Hospital, Valley Medical Center, Kaiser, ) ) ) ) ) the VA, outpatient clinics, family shelters and juvenile ) ) ) ) ) halls—each ) ) ) ) ) suited for a particular rotation: internal medicine, ) ) ) ) ) pediatrics, psychiatry, neurology and ambulatory medicine, to name ) ) ) ) ) a few. She’s learned ) ) ) ) ) how to administer digital nerve blocks and do blood ) ) ) ) ) draws, and she’s ) ) ) ) ) sutured a child’s arm in the emergency room.

During her pediatrics rotation, Ananth experienced her first fatality. “Nothing prepares you for the death of a child,” she says. “It really shook my team up, and opened up [conversations] for interns to talk about how their schedules are so busy, they don’t have time to process deaths [because] they have to show up in clinic that same afternoon.”

Like Oshinowo, Ananth will head to Cal this fall for a master’s in public health. Her out-of-class experiences have been influential as she leans toward a career in community health. Last fall, Ananth traveled to Waveland, Miss., with professor of medicine Samuel LeBaron, ’68, and five other medical students to staff a clinic set up by the hippie Rainbow Family for victims of Hurricane Katrina. Although she says she’s “not a tent-in-a-parking-lot kind of girl,” Ananth spent a week in a Eureka dome tent in the devastated community, treating wounds and administering hepatitis A vaccinations: “I was really changed by the experience.”

A week later, Ananth was on her way to the highlands of Guatemala, where she traveled in the open bed of a pickup truck as she worked with pediatrics professor Paul Wise to provide care for children and families in village clinics. “What we were doing in Mississippi was disaster relief, and likewise in Guatemala, which had come through mudslides after Hurricane Stan,” Ananth says. “Leaving the States really helped me realize what I’m here for—to provide health care to populations that need it most. It’s not about making myself a well-known physician. It’s about serving.”

And that, really, is the goal of the medical school’s redesigned courses: turning out more skilled, more compassionate doctors. “I think the new curriculum will make [students] personally engaged in the excitement of what medicine has to offer,” Parsonnet says. “It’s designed to make medicine less of a ‘career’ and more of a passion.”