MEDICAL EDUCATION REFORM

Pharmacology to Lead Off Second Year, Play Role in Human Systems

Beginning with the 2007–2008 academic year, what had been a five-week block on pharmacology in the students’ first year will now kick off the second year as a two-week introductory block under course director Carl Rosow, HMS professor of anesthesia at Massachusetts General Hospital. (Rosow has directed the Health Sciences and Technology pharmacology course for 13 years.) The shorter block, an introduction to basic principles of pharmacology, does not mean short shrift: the principles Rosow and his colleagues teach will be elaborated upon in the Human Systems (pathophysiology) courses that follow throughout the second year.

Graham Ramsay

More pharmacology content will now be woven through medical education than in the past, according to Carl Rosow (right) and John Pawlowski.

“The pharmacology course isn’t just two weeks,” said Rosow. “There will be more pharmacology rather than less, and it will be taught in a sequence—alongside pathophysiology—that will, hopefully, be more intuitive for the students.”

“The first year is not the best time to teach pharmacology, because learning about drug therapy is difficult when you don’t know very much about the diseases being treated,” Rosow said. His two-week course will introduce students to broad concepts, such as the ways that drugs can be absorbed, distributed, metabolized, and excreted. It will also cover how drugs bind to receptors, how they interact with one another, and how they may cause toxicity. “For example,” he said, “drugs for cardiac rhythm disturbances can cause arrhythmias as well as treat them. Or consider multiple-drug treatments for cancer and hypertension. We will use drugs from both classes to illustrate how they may be combined to increase effectiveness and reduce side effects.”
During their careers as doctors, the students will use drugs that haven’t been invented yet, so training them to be aware of general issues is essential. This introduction will give students the vocabulary to discuss drugs in relation to specific organs and diseases covered in later courses.

Rosow is collaborating closely with second-year pathophysiology faculty and with Pharmacology co-director John Pawlowski, HMS assistant professor of anesthesia at Beth Israel Deaconess Medical Center, on the division of labor and how they will follow up on the principles presented in the two-week introduction. “The key goal of our integration effort is to teach about the basic science and clinical application of drugs in a coordinated way,” Rosow said. “For example, a cardiovascular drug may illustrate an important theoretical principle, but it may also be an important part of clinical treatment. The Pharmacology faculty will introduce this prototype drug by describing its molecular mechanism or dose–response curve, and we will also indicate its place in the treatment of heart disease. Later in the year, the faculty in cardiovascular pathophysiology may review the mechanism, but spend more time discussing the use of related drugs or describing how the pressures and flows in the diseased heart will change from a given dose. The focus is expected to be different, and we believe that student learning will be facilitated by stressing both perspectives.”

The best methods for integrating a longitudinal piece of the curriculum like Pharmacology are currently being determined. Rosow explains that one method might be to swap faculty. “I or one of the other Pharmacology instructors might go into the Human Systems module and give a drug lecture. On the other hand, a cardiologist, nephrologist, or pulmonologist might come and give a lecture in pharmacology.” The syllabus for his two-week introduction, in fact, will cite lectures in other components of pathophysiology throughout the second year.

Students in Rosow’s block will meet every weekday morning and two afternoons a week, totaling 44 hours of study over two weeks—about the same number of hours as his seven-week Health Sciences and Technology pharmacology course.

—Rich Barlow

Human Development: Why People Do the Things They Do

“Why is it that a 17-year-old would take you up on a dare to drink 38 shots of tequila, but a 35-year-old would not, given that their brains are essentially the same in the regions that exercise good judgment?” asked Steven Schlozman, HMS assistant professor of psychiatry at Massachusetts General Hospital. Such questions are the stuff of Human Development, the study of changes throughout a person’s life—biological, cognitive, emotional, and moral—that govern healthy maturation.

Graham Ramsay

In the new course Human Development, co-directed by Steven Schlozman (right) and Jonathan Alpert, students will learn about the normal stages of growth, which will prepare them for the ensuing study of psychopathology.

In past years, this material was distributed among various courses. Now, HMS will join the majority of medical schools that offer Human Development as a stand-alone course. It will take up one afternoon session a week during a five-week block starting in August of the second year, preceding Psychopathology and paralleling courses in both Pharmacology and then neurobiology (called Human Nervous System and Behavior), taught during the same time frame.

It is apt that Harvard is giving the topic this attention, since pioneering work in the field was done at the University by, for example, Erik Erikson. Yet concrete educational concerns rather than homage to the past drove the decision to craft the course. Research suggests that practicing physicians may overlook developmental differences between patients or factors that affect normal development unless the doctors are explicitly trained to do otherwise, according to Schlozman, who co-directs the new course with Jonathan Alpert, HMS associate professor of psychiatry, also at MGH.

A 17-year-old, for example, grasps nutritional counseling in very different ways than a 13-year-old, though otherwise the two patients seem similar. Alternatively, a 35-year-old patient’s age may mask a regression in his reasoning ability caused by the stress of illness.

Case studies will be the crux of the class. Schlozman will contribute one from his own experience: the instance of his then six-year-old daughter fracturing her wrist in a minor accident on a set of monkey bars. That simple incident was the result of a complex web of developmental milestones, Schlozman said. She needed to have acquired emotional confidence that she could master the bars, cognitive skills to judge that she could climb safely, cerebellar development to grant her the necessary fine motor control, and the necessary bone development for the fracture to occur in the first place.

“The point is to study all of these things from a normal perspective,” he said, “because that allows you to recognize when things have gone astray.” And this, in turn, is the focus of Psychopathology, which will follow and build upon themes introduced in Human Development in another example of the new curriculum’s integrated approach.

Schlozman will be joined by instructors from throughout the Medical School, reflecting both the multidisciplinary nature of the field and the technological advances of the last two decades that have enabled the field of human development itself to develop.

“We have the tools now to study what’s going on neurobiologically as people undergo these changes. Most folks would have said a 15-year-old is different from a 22-year-old; now we can construct a postulate, from looking at their brains, as to why these changes take place.” The new capabilities explain why that teenager would drink amounts of tequila his elders would refuse: adolescents, in the heat of emotion, use more primitive areas of the brain to make choices, even though their prefrontal cortex, the font of good judgment, is as fully developed as an adult’s.

—Rich Barlow

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