Making a great medical education even better

By David Nierenberg, MD
Senior Associate Dean for Medical Education

When my friend and colleague, Alumni Relations Director Theresa Bryant, asked me to write about what is “new and different” in the DMS curriculum over the past three or four years, I was happy to respond. When I bump into alumni who have come back to visit, or when I address alumni groups during reunions, this is probably the most common question I am asked. So, here is an overview of changes that have occurred during the past few years.

Year 1

Two years ago the Medical Education Committee recommended that the grading of Year 1 be changed from Honors-Pass-Fail to Pass-Fail. Students had urged this change, suggesting that there was now evidence in the medical education literature that such a change could lead to less stress, depression, and competition, and greater student cooperation in learning, without any decrease in learning or performance on exams.  There was considerable enthusiasm among the Year 1 course directors to try out this change, while keeping a close eye on attendance at lectures, performance on internal DMS exams, and performance on external NBME exams. The 2009-10 academic year was the first year of the change, and faculty and students agree that it went very well indeed. Time will tell in another year about performance on Step 1 of the USMLE sequence, but by all indications this change has been a success.

This year, in August, 2010, we launched an entirely revised Orientation Week for the 94 new Year 1 students. This is something we had been working on (with lots of help and advice from Sue Ann Hennessy, Joe O’Donnell, and most recently Ann Davis) for more than three years. We have retained many of the excellent features of earlier orientations organized by offices such as Student Affairs, Multicultural Affairs, and Student Government. However, we had several additional specific goals, including:

  • introducing students to a real patient on the first day;

  • providing a glimpse of the breadth of the profession of medicine;

  • seeing how doctors work together in multidisciplinary teams;

  • seeing how the healthcare system itself—with issues of quality, safety, cost, and value—is becoming  a more important subject of medical education at every level;

  • meeting faculty in small conference groups;

  • and beginning to see how many different types of careers are possible in the profession.

We accomplished these goals by introducing our new students to a patient with lung cancer. Most of the subsequent sessions viewed the profession of medicine through this prism. For example, students saw a master clinician interview a real patient who was being treated for lung cancer. The patient explained to how he learned of the news; why he had been unable to quit smoking; how the doctors debated the best course of treatment; and how the disease has affected his life.

We organized students into three conference groups, each with a faculty tutor, to discuss a variety of issues related to this case. Students attended a tumor board meeting to observe how doctors from five or six different disciplines combine their knowledge to plan out optimal treatment strategies. There were sessions about translational research to improve the treatment of lung cancer, how tobacco companies induce teenagers to smoke by influencing the content of TV shows and movies, and how students can get involved in smoking cessation clinics. There were additional sessions to help students begin to understand the health-care system, with topics including improving safety and minimizing nosocomial infections, participating in shared decision making, understanding the factors that contribute to regional differences in utilization of health-care resources, understanding how insurance works, and an introduction to the science of safety and improvement.

Detailed surveys completed by the new Y1 students, indicate that this new orientation program, with much more content about the profession of medicine and the health-care system, and less time spent on things like in-person registration and administrative paperwork, was very well received.

Year 2

A few years ago we added an introductory one-week courses titled “Major themes in SBM” (Scientific Basis of Medicine). These were the key themes that would be important in nearly all of the following SBM system-based courses, including pediatrics, pathology, imaging, improvement, nutrition, neoplasia, and genetics. This introductory course has been well received, but a complaint in prior years was that the topics sometimes did not appear to hang together well and seemed somewhat disconnected. To remedy that concern, this year’s course was introduced by a new clinical case delivered in the format of a CPC, with Dr. Rich Comi (associate director of SBM) acting as the expert case discussant. We modified a case that had appeared as a CPC in the NEJM several years earlier.

This case involved a young girl (pediatrics) who had been cured of a myosarcoma at age 3 and who developed a mediastinal mass at age 8. The mass (issues related to proper imaging here) turned out to be a new lymphoma (neoplasia), which required some specific genetic analysis. Diagnosis relied on pathologic interpretation of the biopsy, and nutrition issues surfaced when enteral and then parenteral nutrition became necessary due to side effects of treatment. The improvement issue in the case surfaced when the patient, recovering from surgery in the ICU, developed a nosocomial infection. The use of a clinical case presented in a CPC format really seemed to help to tie together the different themes of the course, according to our survey of students as they completed the course.

Year 3

Student feedback over several years indicated that one of their most common concerns was the lack of opportunity to take an elective in Year 3. With six core clerkships, and six clerkship blocks, there simply was no time for that. With lots of helpful advice from students, and flexibility on the part of clerkship directors, we were able to create a schedule that includes seven clerkship blocks, one of which can be spent taking one or two short electives, vacation, or extra time to study for Step 1 of the USMLE. This new system seems to be working well for both the clerkships and our students.

Another nice addition to clerkships is the opportunity to take some clerkships at distant sites that offer a greater variety of types of sites, patient conditions, and exposure to care of patients from cultural backgrounds quite different from those seen in rural New Hampshire and Vermont. Alums already know about the popularity of family medicine clerkships in sites like Tuba City, Ariz. and Bethel, Alaska. We have recently added a new pediatrics site at Fort Defiance, Ariz.

We also have a new affiliation agreement with California-Pacific Medical Center, started in 2008, which is going extremely well. DMS students can now elect to take all of our clerkships except surgery at this site. They experience excellent clinical care and superb teaching in a large urban academic health center, which cares for a great variety of patients from different cultural backgrounds. (Many patients are from Mexico, Southeast Asia, Russia, China, etc.) These diverse distant clerkship sites are a wonderful complement to the excellent experiences that students have taking clerkships at DHMC, the VA Medical Center in White River Junction, and our many regional office sites in New Hampshire and Vermont.

Throughout all four years, we continue to look for ways to introduce more material into existing courses and clerkships in the area of understanding the healthcare system, and improving its quality, safety, efficient utilization of resources, and overall value. We have woven these themes into Year 1 orientation, various aspects of SBM, most of the clerkships, and several of our capstone courses in Year 4. This is important material, which Dartmouth College President Kim has described elegantly as “the science of health care delivery.” And with The Dartmouth Institute and its many expert faculty right in our midst, we need to make sure that our graduates are prepared to help lead the charge nationally toward a higher quality, safer, more efficient health-care system.

Finally, urged forward by new LCME detailed requirements, we are looking inward and studying what specific competency items we are teaching, and how we are assessing whether students are achieving a level of mastery that is appropriate for each course, clerkship, and year. Is “On Doctoring” optimally equipping our students to move on to clinical clerkships? Is SBM preparing our students to understand the pathophysiology of the diseases they will see during their clerkships?  Is “Clinical Pharmacology and Therapeutics” preparing all of our graduates to be effective, safe, and cost-conscious prescribers?

I hope you can see from the changes and improvements outlined above that we think a DMS education is a great one, but we are always looking for ways to make it better. Your suggestions are always welcome, since our alumni bring a unique perspective to bear. Please feel free to send me your comments. I look forward to seeing many of you at various alumni events.

September 2010