|
||||||||
|
FORUMMedical Frontiers: Where Art and Science Meet Global Economics
Medicine—a very practical profession it seems. You learn basic principles, hundreds upon hundreds of facts, and then begin applying this knowledge to clinical situations. You integrate feedback from all your senses and reconsolidate these basic principles and facts into deeper, more meaningful contexts. The sight of enlarged retinal vessels, the whooshing of blood through an atherosclerotic artery, the texture of a breast nodule, certain smells, and that sour taste in your mouth when you understand the gravity of a diagnosis all combine, enabling you to treat that patient with skill and compassion. Your hands, eyes, and ears—and your mind—work together to change the lives of patients. It is this aspect of medicine, the very real connection between one's own skills and the application of these skills to affect someone in such a palpable way, that attracted me to the profession. Making Treatment MatterBut that's not the whole picture. Far from it. How did the patient get to the health center? By car or train or subway through the streets of some Northeastern metropolis? Or by foot, over ten miles of a dusty, hot, Sahelian landscape? Who pays for the patient's care? Does the patient arrive well nourished or anemic from chronic hookworm infection? With stunted growth, retarded cognitive development, or desperately ill because his family could not afford to get him medical care until very late in the course of illness? Does my patient understand how to use the drugs I am prescribing? Will she be able to take them every day, some on an empty stomach, others during a meal? Will society ostracize my pediatric patient when it is found out he has AIDS, acquired as a fetus or through a blood transfusion?That is to say, as a physician, one could understand the mechanism of disease down to the level of a signal transduction cascade or a single base pair deletion, and the patient's inability to comply with the treatment regimen would make this knowledge useless. Utterly useless—not very practical at all. Medical Dollars and SenseThis summer, as I began the transition from medical school to graduate school to study health economics, I moved away from thinking about the mechanisms of disease, to understanding the very real and very practical issues associated with getting care to patients. Development and delivery of vaccines, reforming health systems, financing of drug delivery—these were all issues I studied for the past few months as an intern at the World Bank.These issues were not new to me. I have been interested in health policy, particularly the application of policies aimed at improving health conditions in developing countries, for several years, since completing a thesis on HIV vaccine development as a molecular biology major in college. It was then, while immersed in the various strategies to elicit long-lasting immunity to HIV, that I began to explore many of the social and economic impediments to vaccine development. Banking on HealthThe World Bank, established as one of the Bretton Woods institutions at the end of World War II, is deeply invested in efforts to improve health in developing countries. Through its concessionary lending, the bank supports country-level projects ranging from development of health systems to construction of health posts to vaccination of children as part of the international campaign to eradicate polio. As an intern in the Human Development Network, my work focused broadly on health projects, vaccines and immunization in particular. Microbiology seemed quite distant when I was thinking about net present value, manufacturing scale-up issues, and delivery costs.At the same time, however, medicine and economics never seemed more intertwined or essential to each other. While I was learning about the costs associated with developing a particular vaccine, for instance, I also had to understand the nature of the pathogen, the kind of immunity the vaccine candidate was aimed at eliciting, and the infection patterns of the disease. Transmission patterns, mutation rates, and the like all have great bearing on both the development and the delivery of health interventions. The synergy between the two fields was not unexpected. I've actually been betting on it since deciding to pursue graduate studies in health policy, with a focus on economics. Much more than being simply practical, medicine is wonderfully rich and textured. It's a profession where social and economic forces are magnified, and the consequences of one's actions can send ripples through the lives of patients and their families. —Erica Seiguer, a third-year MD–PhD student at HMS
German Students Help Blaze New Pathway in MunichFor students at HMS, the following may sound like an everyday example of clinical teaching at a Harvard-affiliated hospital.
The attending physician is already waiting in the room. We say hello to each other, chat for a little while, and sit down for an hour of teaching. As we present our patients, she listens carefully, gives feedback, points out the good parts of our work, and offers suggestions for improvement and alternative strategies. After we have discussed the cases and some relevant literature, she says, "Why don't we go and see your patients?" At the bedside she shows us how to examine the patient, elicit crucial findings, and conduct the interview in a time-efficient but pleasant way. She gives us advice about how to establish a cooperative, empathetic relationship. Though this may, indeed, be an everyday occurrence at HMS, we came all the way from Germany to study for six months in order to get this experience ourselves. Why the effort? Germany's ModelGerman medical education is well known for its focus on extensive and systematic teaching of the basic sciences and pathophysiologic concepts. In our country, students enter medical school after finishing high school at around age 19 without attending an intermediate college. Medical school consists of two preclinical and four clinical years, starting off with the basic sciences and much laboratory bench work and anatomical dissections.The clinical part is more theoretical and predominantly takes place in seminars and lectures. Diseases are more frequently discussed using a systematic rather than a case-based approach. Hands-on clinical experience is not an integrated part of the curriculum as it is at HMS, but something students are expected to gain in self-organized electives during lecture-free months. German students also are expected to do more research than American students during their medical school phase: most students work on a scientific thesis during their clinical years, which is required for the doctoral title. Thus, the transition from this highly theoretical and scientific medical education to the clinical clerkships in the last year of medical school is rather abrupt. Putting Patients FirstThe medical students in Germany have been demanding a more clinical and patient-centered curriculum for many years. They find it increasingly difficult to apply their theoretical knowledge to daily patient care. The faculty of Ludwig Maximilians University (LMU) in Munich was among the first at a German university to launch a reform initiative, and it established a partnership with HMS to integrate elements of the New Pathway into the traditional training. Since 1997, four problem-based learning courses have been introduced into the LMU curriculum and have been received by the students with great enthusiasm.This Munich–Harvard Alliance for Medical Education is an innovative and visionary step forward to expand medical education within Germany, where education is free and the universities are almost exclusively state funded. In this highly centralized system, the individual university has little autonomy over its curriculum or even its admission of medical students. The alliance has received much academic and public attention and several national awards. It now serves as a role model for other German medical schools in a combined effort to achieve changes in the current system. As part of this alliance, the LMU faculty sends 10 final-year students to Boston each year for six months to gain insight into the didactic concepts behind the New Pathway through participating in clinical core rotations, electives, and a specially designed course in medical education. The Recommended UpgradesWhat are the specific differences between the two educational systems? From our experience in the alliance program, we see three major features of clinical training at HMS that would add considerably to the LMU curriculum:Interactive Learning. We greatly profit from the small-group setting in clinical tutorials, clerkship groups, and attending rounds since it fosters an interactive learning style. The close interaction with teachers in a collegial atmosphere is highly motivating for us as well as for the teachers. A more interactive teaching style in Germany could be achieved by reducing the number of lectures and increasing that of tutorials, small-group seminars, and bedside teaching. Role-modeled Learning. Experiencing role play in tutorials, taking on responsibility for inpatient care on the floor, and following outpatients over an extended period in the Primary Care Clerkship are examples of successful role-model learning. Taking an active part in caring for patients is ideal for learning history taking, physical examination, and presentation skills and for refining interpersonal approaches to patients. Evidence-based Learning. Accepting responsibility for adequate diagnostic and therapeutic interventions and presenting these in team rounds prompts us to do case-related reading and literature searches. This ensures that evidence-based thinking and clinical decision-making become routine parts of our patient care. Classic FeaturesYet there are features of traditional German medical education from which we benefit enormously. The sound theoretical knowledge of preclinical sciences and the deep understanding of physiological and pathophysiological processes have been of great value throughout our clinical training. There is also a broad exposure to various clinical specialties, such as ophthalmology, dermatology, and ENT, which gives an overview of patients' medical problems and a deeper understanding of their interrelations.We greatly enjoyed our six-month rotation at HMS, which we complete this month. We are optimistic that combining the strengths of the HMS and the German systems will lead to a medical education in Germany in which students are thoroughly prepared for their patients' needs and the challenges of the rapidly evolving fields of modern medicine. We will continue trying to blaze a New Pathway for Munich's medical students that will render them uniquely trained in our country. The Munich–Harvard Alliance for Medical Education now offers HMS students the opportunity to go to Munich on exchange and experience the classic German curriculum combined with innovative teaching elements. We would be happy to assist HMS students by providing information and helping to arrange rotations. If you are interested, please contact one of us at peter.galambos@stud.uni-muenchen.de or ralf.jox@gmx.net. —Peter Galambos and Ralf Jox |
