MED ED REFORM

The Anatomy of Patient–Doctor II

Last spring, Focus ran a series of vignettes describing the revamped courses that incoming students would take beginning in August 2006, when the phased introduction of the new medical education curriculum began. Now we are running a second series of vignettes, covering changes in the second year of the curriculum. The first one, on Patient–Doctor II, is below.

The Patient–Doctor II course is the spine of the reformed second-year curriculum. PD-II gives students hands-on instruction in how to conduct a physical examination. Now, the new second-year Human Systems course will graft its schedule of basic science instruction onto the teaching schedule followed in PD-II, said William Taylor, HMS associate professor of medicine at Beth Israel Deaconess Medical Center and PD-II’s director.

Photo by Graham Ramsay

William Taylor (center) is director of Patient–Doctor II while Robert Stanton (left) co-directs the closely coordinated course Human Systems with Barbara ­Cockrill (right) and David Cardozo (not pictured).

Robert Stanton, HMS associate professor of medicine at Joslin Diabetes Center and co-director of Human Systems, describes the coordination: “We talked with Patient–Doctor II and asked, what is the magic order in presenting human systems? What would work best for the way that Patient–Doctor II teaches exams in the hospital?”

Past efforts at coordination achieved some success, but could be haphazard, with some topics being taught out of sequence from the work done in the PD-II exam room. The best example of curriculum reform improvement will be the musculoskeletal system. Teaching students to perform that exam “is now going to be beautifully coordinated with a musculoskeletal medicine segment of Human Systems that’s going to occur early in the second year,” according to Taylor. Under the old curriculum, musculoskeletal science was taught in the spring.

“The Human Systems faculty were good enough to move the musculoskeletal system into the fall,” he added. “It turns out that the musculoskeletal exam is one of the most challenging for students to learn. We have always needed to teach the examination of this system early in Patient–Doctor II to allow students to practice the exam repeatedly throughout the course. In the new curriculum, students will learn how to examine the musculoskeletal system when they are learning its pathophysiology, a combination that always works best.” This new integration will follow an existing coordination early in the fall, in which studying the nervous system is coupled with learning how to do a neurological exam in PD-II.

The result will be a seamless continuum. “What we will be saying to the students is, ‘Examine the patients, doing all the things we’ve taught you so far.’ Piece by piece, we build up the components of the physical exam.”

Taylor also suggests that students studying medical insurance in the new year-two fall-semester course Introduction to Health Care Policy could, as part of their PD-II work, inquire about their patients’ coverage and whether it has impeded their ability to get care.

Absolute coordination is impossible. A hundred-plus students studying valvular heart disease in the morning won’t each get a patient with that condition in the afternoon. “But you can say, ‘This afternoon, tell me whether your patient has valvular disease and how did you figure that out?’ The patient may not have the disease, but the exercise for the student to determine that would be related to the material learned in the morning.”

The newly truncated second year will require rejiggering the frequency of PD-II sessions. And while students will still divide up among nine clinical teaching sites, there are tentative plans for more and regular full-class lectures during the first semester.

—Rich Barlow

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