Harvard Medical School
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The Solution For Heart Disease

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The Harvard Medical School probably has the most prestigious reputation in the general public.  Certainly the Harvard Medical School is one of the most influential medical schools on the planet.  This page starts with the little-known criticism of the Harvard Medical School by none other than one of the most famous of the Presidents of Harvard University, Dr. Derek Curtis Bok.  Dr. Bok was the President of Harvard University for 20 years, from 1971 to 1991.  He introduced many changes to that great University.  I, Karl Loren, have actually received my MBA Degree from the Harvard Businsss School.

This page includes articles or pieces of information about the Harvard Medical School, taken directly from Harvard sources.

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Dr. Derek Bok
Article

Stirrings of change are evident elsewhere in the United States. In 1982, the Macy Foundation sponsored a major conference that urged far-reaching reforms in the teaching of medical students. I The Institute of Medicine has just come forth with a study on medical education and societal needs.2 For the past two years, a blue-ribbon committee appointed by the Association of American Medical Colleges has been studying medical education and will soon issue a report.

We have grown so used to a world of miracle drugs, open-heart surgery, kidney transplants, and CAT scanning that we can scarcely remember the primitive state of medical science only -A. few generations ago.. Not until this century could patients expect to improve their chances of survival by entering a hospital. 3 Looking back to his boyhood in the 1920s, Lewis Thomas recalls how frustrated his father felt over his constant inability to comprehend, let alone cure, the ailments of his patients.4 Even in the late Thirties. after entering Harvard Medical School, Thomas recalls that "it gradually dawned on us that we, didn't know much that was really useful, that we could do nothing to change the course of the great majority of the diseases we were so busy analyzing, that medicine, for all its facade as a learned profession, was in real life a profoundly ignorant occupation.

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patients of modest means are finding it harder to get adequate medical services when they need them.

The expansion of health services has also brought new problems in its wake. By the mid 1970s, experts began to warn that the stimulus of government programs had worked too well. Julius Richmond, former assistant secretary for health and Surgeon: General, claimed that hospitals now had 150,000 more short-term beds than the nation actually needed.6 According to the Graduate Medical Education National Advisory Committee,

Changes have occurred in the content of courses. But the methods and the structure of medical education have stayed surprisingly constant through the postwar period.

medical schools had expanded to the point that the nation could expect a surplus of 25,000 to 50,000 doctors by 1990.7 The Institute of Medicine opined that far too many of our doctors were specialists and far too few were general practitioners.8

Worse yet, the methods used by the government and private insurers to pay the cost of care for the aged and indigent carried no incentive to restrain expenditures. As a result, aided by the rapid growth in the number of hospital beds and practicing physicians, medical bills shot up much faster than the cost of living. Whereas the total cost of health care had consumed only 5.3 percent of the Gross National Product in 1960, the proportion rose above 10 percent by 1983, amounting to more than $350 billion per year. No other industrial nation devoted a larger share of its resources to this purpose, and most spent considerably less.

These burgeoning costs in turn have had repercussions throughout the health care system. A host of government rules have sprung up to fix the maximum price the government will pay for medical services and restrict the right to construct new hospital facilities. To foster competition, federal officials have encouraged health maintenance organizations, which offer prepaid care at prices below Blue Cross and other established insurers. Chains of hospitals operated for profit have also expanded rapidly to take advantage of growing health care markets. More recently, coalitions of corporations, unions, and doctors have formed to search for ways of curbing the rise of health care bills. These developments promise not only to trimsform the health system but to affect the nature and quality of care itself For though the initiatives are very different, they do have one thing in common. All of them carry potent new incentives to press down medical expenditures. The great unknown is whether these incentives can succeed in restraining costs without causing providers to dilute the quality of care.

The Response of Medical EDUCATION

With such extraordinary advances in scientific knowledge, not to mention the metamorphosis of the health care system and its attendant policy problems, one would have expected comparable changes in the shape and substance of medical education. In fact, such changes have occurred in the content of courses. Instructors have been quick to tuck the latest scientific findings into their classroom lectures and their discussions on hospital wards. But the methods and the structure of medical education have stayed surprisingly constant through the postwar period. In order to enter medical school, college students must still take

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work in mathematics, physics, biology, and chemistry. Once admitted, they continue to spend much of the first two years listening to lectures on basic science-biochemistry, anatomy, microbiology, pathology, neurobiology, physiology, and pharmacology. During the last two years, they still enter the hospital for clinical rotations under the tutelage of professors and house staff, who teach them the arts and skills of taking medical histories, finding further information through various tests and procedures, and eventually making diagnoses and prescribing appropriate treatments.*

If the structure and methods of medical education have stayed more or less the same, so also have the criticisms and complaints. Educators have long observed that premedical requirements and prevailing admissions practices push college students into majoring in science and stir anxieties that distort the course selection and even the extracurricular activities of many undergraduates. For years, these comments were largely anecdotal. But recent research confirms the diagnosis. A survey of undergraduates in leading liberal arts colleges revealed that premeds feel greater stress than students interested in other occupations and are more likely to alter course selections and extracurricular activities to favor their chances of admission to medical school.9 Fifty-three percent of the premeds in this survey felt that a substantial minority of their fellow students disliked them, while 24 percent believed that instructors expressed negative feelings toward them. Forty-five percent of all undergraduates who dropped their plans to become a doctor did so because they did not wish to enter a profession with a group of students who seemed so grimly purposeful and ambitious. Still worse are the persistent reports of cutthroat competition, buttressed by a study of 400 medical students in which 88 percent admitted having cheated at least once during college. 10 (This study is especially ominous since it found a positive correlation between cheating in college and dishonesty in the process of patient care.)

It is hard to overcome such pressures completely as long as there are many more aspiring doctors than places in our medical schools. Even so, except for experiments by a few schools, most of them financed by the Macy Foundation, one is struck by how little medical faculties have done to improve matters by reviewing their admissions practices and premedical requirements.

The problems of the first two years of medical school have also changed but little over the past few decades. Much of the instruction still consists of lectures in which a procession of teachers relate large quantities of scientific material to a passive student audience. The sheer weight of this material has jumped dramatically with the cascade of discoveries that followed the work of Crick and Watson on the structure of DNA. Thus far, however, faculties have typically reacted by packing their lectures more densely and cutting back on laboratory classes and independent study to make room for still more lectures.

In response to student complaints, faculties have tended to increase the number of electives or provide a bit more contact with "live" patients-palliatives that do not really attack the underlying problems. Increases in faculty size, far from encouraging mom tutorial and small group instruction, have led professors to specialize more narrowly and expect lighter teaching loads. Thus, courses today are commonly divided among many lecturers in a long disjointed "parade of stars" in which the professors, one by one, appear before the students to describe

* Greater changes have occurred in the residencies that make up graduate medical education, but that is a subject beyond this report, which is entirely concerned with the general preparation given to all physicians that culminates in the M.D. degree.

new developments in their specialty. Since more and more of these instructors have received their degrees in basic science rather than medicine, their classes often seem to have little relation to the patient care that attracted most of their students to medical school in the first place. Worst of all, the lecture system encourages a static, passive attitude toward education that emphasizes memorization instead of the active, inquiring cast of mind required to keep up in a rapidly changing field. I I

After the first two years, medical education turns highly practical. Students begin their clinical rotations in the hospital, learning the rudiments of surgery, medicine, pediatrics, and other fields of practice. At this stage, the instruction is much more relevant to the students' professional lives. The tedium and abstraction of the first two years give way to the total absorption of working with live patients. But new complaints come to the fore. Despite the huge increase since World War 11 in the size of the clinical faculty, students feel that they get too little instruction from professors and too much from hospital residents and interns only slightly older than themselves. They often find the content of rotations unpredictable, the objectives vague, the feedback far from adequate.

More experienced critics expand on these complaints. In commenting on the quality of teaching in the wards, they claim that students are forced to play too passive a role with insufficient opportunity to practice the skills of seeking out informa- making tentative diagnoses, testing their hypotheses with further information, and eventually reaching a final conclusion. They likewise complain that students have too little exposure to the psychosocial aspects of patient care and too little discussion of preventive measures or the problems of conserving costs in gathering information and prescribing treatment.

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A final criticism that applies throughout the curriculum is the lack of attention paid to the nonscientific side of medicine. Only a minority of medical faculties require their students to take a course in medical ethics, the history of medicine, behavioral science, or the organization and economics of health care. Granted, such subjects have now been introduced as electives in almost all schools. But these offerings rarely have much status in the curriculum or gain reinforcement by being integrated systematically into the clinical rotations. A look at the Harvard Medical School illustrates the problem. At present, Harvard students must take six of their 134 required credits from courses listed under Behavioral Sciences, Social Science, or Preventive Medicine -- categories that include such offerings as Medical Ethics; Social History of Medicine; Literature and Medicine; Organization of Health Care; Forensic Pathology; Psychiatry and the Law; Culture and Illness; Religion and Medicine; and Science, Sex and Gender. Such requirements carry a message that all these courses together are of slight importance in the total curriculum, that each is equally relevant to the practice of medicine and that none is important enough to be required of every doctor. With this equivocal endorsement, in an environment dominated by science and research, small wonder that only three or four students in each class of 165 actually choose to take more than the bare minimum of these subjects.

These criticisms of medical education have been repeated many times. Most of them have been heard for over seventy years. A group of Harvard professors in 1847 made all the familiar arguments against the overuse of lectures when they opposed a move by the American Medical Association to lengthen the curriculum. Abraham Flexner, the father of modem medical

education, restated these points and also called insistently for efforts to balance medical science with greater concern for the psychological and social aspects of health. Professors early in this century even questioned the effects of premedical requirements on undergraduate education when the prerequisites were first imposed.

This record provokes an important question. Why has medical education changed so little in the face of such persistent criticism, especially during an era when the field of medicine has changed so much? One important reason is that teaching stands low on the totem pole of medical school incentives. Academic advancement, professional recognition, and public acclaim all go to those who succeed in research. If the rewards of prestige favor science, the material incentives favor patient care. Teaching hospitals need academic physicians who can attract patients and fill beds, and rapidly growing faculty practice plans offer lots of money to clinicians who can do just that. Many earn over $150,000 a year, and incomes of $300,000 to $400,000 are not unknown for part-time clinical professors.

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Lured by such attractive incentives, few faculty members have a strong interest in teaching and most spend little time at it. Moreover, among the various types of students that pass through medical schools and teaching hospitals, ordinary medical students rank well below the top in competing for whatever time and attention professors are willing to give. The scientists who make up the preclinical faculty am chiefly concerned with their Ph.D. students and postdoctoral fellows, who. are wholly dedicated to research. To the clinical faculty, residents and fellows often seem more interesting than medical students, since they are more advanced and committed to the very specialties their professors practice.

In this environment, it is not surprising that medical education resists change, especially in the most prestigious, research-oriented schools. Basic reforms require a lot of work-to change pedagogic styles, to develop new instructional materials, to endure the frustrating trials and errors of developing novel ways of teaching. Since none of the typical incentives and rewards of academic medicine reinforces such activities, few professors will devote the time required. In addition, medical schools command less influence among their faculty members than other academic units in the university. Professors owe obligations to their hospital, where they work and receive their salaries; to their departments, which depend far more on patient fees and federal research funds than on the medical school; and even to their professional societies, which confer prestige on their members and often declare their own views on medical education. Amid these competing loyalties, most medical deans have little leverage to engineer major educational reforms.

There is yet another, subtler force at work to inhibit change. In all professions, formal education is shaped to fit the prevailing sense of how practitioners go about resolving the characteristic problems of their calling. The Harvard Business School faculty molds its curriculum and teaching to instill what F. J. Roethlisberger has described as "the administrative point of view." 12 Law professors, especially in the critical first year, teach their classes to help students learn to "think like a law- to identify legal issues in human situations, to marshal all of the evidence and arguments on every side of each issue, and then to determine which solution best fits the legal precedents and policy considerations that bear on the problem at hand. So long as the prevailing conception stays unchanged, faculties are unlikely to alter the curriculum very much.

Medicine has its own idea of what it means to "think like a doctor," even though physicians may be less explicit about it than their colleagues in business and law. At the heart of this

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conception is a view of human disease as a scientific phenomenon consisting of deviations from a biomedical norm. Such deviations are thought to result from a determinate cause or set of causes that are somatic or biochemical in nature. It is the physician's job to ascertain these causes by powers of observation supplemented increasingly by diagnostic tests and other technological aids, and then to cure the ailment or at least alleviate its effects through surgery, medication, or some other course of action. Doctors cannot always diagnose a disease, since their knowledge is limited. Within the realm of what is known, however, they aspire to reach a scientifically certain diagnosis by making all the relevant observations and tests, while looking to research to narrow their ignorance through the discovery of scientific truths.

Professor Donald Selden aptly summarized the traditional view in his 1981 presidential address to the Association of American Physicians:

Medicine is a very narrow discipline. Its goals may be defined as the relief of pain, the prevention of disability, and the postponement of death by the application of the theoretical knowledge incorporated in medical science to individual patients. 13

This conception of the doctor's role has had a marked effect on the nature of medical education. In a profession that emphasizes scientifically determined findings, rather than the rough judgments characteristic of lawyers and business executives, professors are inclined to impart knowledge didactically, as truths to be described rather than problems to be discussed. Matters outside the domain of science command little attention. Although everyone knows that psychological and behavioral factors can influence health, doctors have tended to regard these matters as unscientific and have left them largely to otherspsychologists, social workers, public health officials, and the like. It is only natural, then, for medical schools to push such subjects to the margins of the curriculum. Similarly, since ethical issues and patient values have little effect on the scientific determination of disease, they have not loomed large in the thinking of physicians or faculty committees, at least until recently, when the law courts and the media began to make such problems too prominent to ignore. Much the same has been true of other subjects relevant to health, such as the prevention of disease, the cost and equitable distribution of medical services, and the development of health policies and regulations. Because these topics are peripheral to the scientific analysis of illness, they have either been relegated to secondary status in the curriculum or left to other faculties such as public administration and public health.

New FORCES IN THE MEDICAL ENVIRONMENT

Despite its restricted focus, the traditional conception of the doctor's craft rests on firm foundations. Science has vastly expanded our knowledge of the causes and cure of disease. The progress has been so impressive and its results so abundant that no account of modem medicine could fail to place the application of scientific knowledge at the very center of the enterprise. This empirical support is buttressed by compelling psychological forces. Because medical decisions have such vital effects on human lives and the consequences of error can be so severe, both doctors and patients have strong motives for believing in the accuracy and scientific authority of the physician's judgment. With these achievements and attractions, the tradiconcept has much to recommend it. And yet, new forces have developed that promise not to downgrade science but to expand the physician's role to encompass added problems and complexities.

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The growth of scientific knowledge itself is pressing hard against the familiar notion of what it means to think like a doctor. The constant flow of new discoveries makes impossible demands on human memory. In a world with more than 10,000 scientific journals, the traditional library can no longer succeed in giving practitioners quick, efficient access to knowledge. Already, almost 40 percent of physicians in one survey said that they could no longer keep up with developments in their field. 14 Thus, doctors increasingly need to know how to use the computer to aid them in retrieving useful information.

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Rising quantities of knowledge not only place heavier demands on human memory but create new difficulties in analyzing problems. Scientific progress constantly expands the range of alternative diagnoses to be considered and the number of tests that can be given to test the clinician's hypotheses. Keeping these possibilities in mind, assessing the risks of harm- side effects from a growing number of tests and drugs, calculating the meaning to be derived from larger quantities of data-all are tasks that burden the most sophisticated minds. In the future, the public will undoubtedly make matters even harder by insisting that doctors search for diagnostic informa- and prescribe methods of treatment in ways that are not only effective for the patient but efficient for society by avoiding unnecessary tests and procedures.

In coping with these problems, most physicians are handicapped by their inability to work effectively with complex, quantitative data. Investigations consistently show that they often detect correlations where none exist, cling tenaciously to estimates based on poor information, and exaggerate the informational value derived from small samples. 15 As problems grow more complicated, such weaknesses become more costly; to avoid them, doctors will need to be proficient in the uses (and also the limitations) of statistics, computer analysis, and decision theory. Thus, it is not surprising that a recent poll of Harvard Medical School faculty and students revealed that the four skills most in need of greater emphasis were "assessing cost-benefit and risk-benefit considerations in the use of therapeutic technology"; "avoiding the collection of unnecessary information"; "seeking lower cost solutions to clinical problems"; and "using accepted principles of statistical inference from samples."16

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Even more revolutionary are efforts to devise computer programs to diagnose illness and thus supplant physicians in the most central of their thought processes. For a few conditions, such as rheumatic heart disease, machines can already perform better than physicians. As yet, however, there is little prospect that computers will displace human judgments for a wide range of illness. What is likely is that machines will supplement the human mind by storing and manipulating large quantities of

relevant data and by supplying an independent source of diag- to enable doctors to check their own judgments. Once again, therefore, physicians will continue to need their tradi- skills but will have to know how to make effective use of computers as well.

New technology intrudes in yet another way by confronting doctors with a wider and more complicated array of ethical dilemmas. Now that life-sustaining techniques can prolong vital functions long after conscious feeling has disappeared, doctors ask whether there is any point, let alone moral duty, to maintain life on such austere terms. Complicated operations may save a child but at a cost so great that one can no longer avoid the problem of deciding what price to put upon a human life. Prenatal diagnosis may lead to moral problems if parents request abortions in order to avoid having children of a particular sex. There is no escape once dilemmas of this sort arise. With the rapid growth of malpractice litigation, not to mention investi- journalism, such issues cannot be ignored any longer, even by the most scientifically inclined physician.

Another significant development is the growing awareness of the importance of psychological and behavioral factors in medical practice. Some statistics help to illustrate the point. Between a third and a half of all patients who visit primary care physicians have no physical (or biomedical) ailment at all. Yet studies show that physicians are much more likely to overlook significant emotional and cognitive disorders than physical ailments and Symptoms. 17 Shame, guilt,. and other psychological factors also affect what patients say to their doctors. In fact, studies of patient interviews indicate that up to one-half of all prior hospitalizations and other significant medical incidents

Michael Lutch

am not communicated at all. Is Doctors who fail to detect these psychological and social considerations can easily misperceive the nature of the case -before them and resort to unnecessary surgery, overuse of drugs, and needless diagnostic tests - with no relief for their patients. Through lack of empathy and con- they can drive ill and disabled people to experiment with fads, "miracle" cures, and other treatments of dubious value.

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Psychological and social factors may also affect the incidence of disease itself. For example, recent studies suggest that acute grief can suppress the immune system and thus render a person

Doctors will need to be proficient in the uses (and also the limitations) of statistics, computer analysis, and decision theory.

more susceptible to illness; conversely, conjugal love and support appear to lower the risk of angina. 19 Doctors themselves can influence the course of sickness and cure by their behavior toward patients. Thus, a series of studies has revealed how efforts to prepare patients to cope with impending surgery can shorten the period of hospitalization and recoveiy.20

Investigations have also shown that more than 30 percent of all patients fad to take the medicines or follow the treatments their doctors prescribe. Studies have revealed that over half of such persons do not even understand what they were told to do and that their doctors are usually at fault.21 Presumably, even more people might follow their prescribed treatment if doctors were more adept at persuading them to do so. By virtue of their expertise and their involvement with people at particularly vulnerable times in their lives, doctors are strategically placed to persuade their patients to follow treatments and change their habits in life-enhancing ways. As psychologists have revealed, however, physicians can exert such influence effectively only if they will take the time and develop the skill to engage their patients actively in an effort to understand the need to alter their behavior. 22 In other words, effective practice again requires an understanding of psychology as well as biomedical science.

The final force pressing in upon the doctor is the nationwide concern over rising health costs. Over the next generation, this problem is bound to grow. On the one hand, expenses will continue to be pushed upward by increases in the aged population and in the number of doctors. On the other, government, corporate employers, unions, and large insurance carriers have become concerned enough over spiraling medical bills to resist with determination. A major battle is clearly in the making. Government regulations will probably become more intrusive. Health maintenance organizations, government agencies, coalitions of employers, unions, and carriers, even for-profit hospital chains, will press increasingly for lower costs. To achieve their ends, these organizations will try to limit the doctor's authority over patient care by imposing checks on decisions to hospitalize patients, set the length of hospital stay, or order the use of expensive procedures and tests. In order to avoid unwarranted restrictions, let alone contribute to the national effort to contain rising costs, physicians will have to know more about the issues of health care policy and administration.

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Transcending these developments and drawing from them all is a growing change in the perception of how physicians go about making their characteristic decisions of diagnosis and treatment. 23 Fewer doctors are now inclined to think of themselves as simply arriving at logically determined conclusions

by applying scientifically tested truths to experimentally derived data. The world today seems much more complicated. Doctors are constantly forced to make educated guesses based on imperfect information. Diseases often have multiple causes, not all of them scientific in nature. The information physicians receive, the symptoms they observe, the outcome of the treatments they prescribe, can all be affected by the ways in which they act and interact with patients. The decisions they make are limited not only by gaps in biological knowledge but by bureaucratic rules and economic pressures. In short, the doctor's world cannot be restricted to science or neatly divided between the known and the unknown. Considerations of many kinds are often jumbled together to form a picture full of uncertainties, requiring the most delicate kinds of judgments and intuitions.

This conception of the doctor's craft may not be entirely new, but it is surely understood more widely and more vividly than ever before. In its wake come many questions. How does one make wise judgments or probabilistic estimates from various kinds of imperfect data? If doctors do not simply act on scientific truths but often take calculated risks, how much should they tell their patients and how big a role should the latter play in deciding what chances to take with their own health and wellbeing? Since looking for evidence costs money-over $20 billion are spent each year on diagnostic tests alone- how much information should clinicians seek and how can they search for data in a more cost-effective manner? Finally, if the doctor's behavior helps determine what patients reveal about their ailments, -how quickly they recover from an operation, or whether they follow a prescribed treatment, how can physicians conduct themselves to exert the most constructive influence?

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clinging resolutely to their traditional role as applied scientists seeking accurate biomedical explanations for a patient's disease. After all, it is hard enough to cope with the mounting complexity of the biosciences without having to take account of computers, decision trees, health care regulations, ethical constraints, and the vagaries of patient psychology. But is there a viable alternative?

Conceivably, doctors could try to avoid these complications by delegating responsibility to others. Hire philosophers, as a few hospitals have done, to deal with difficult ethical dilemmas. Leave the psychological problems of patient care to psychiatrists, social workers, and members of the clergy. Find more skillful administrators in the hospitals to cope with government regulations, and trust the AMA to make sure that public officials do not press too far on the doctor's prerogatives. Refer the statistical manipulations and data analysis to computer experts who will advise physicians on request.

Tempting though this response may seem, it is bound to fail in the end. The point is not that social workers, administrators, lobbyists, ethicists, and computer analysts are incapable of helping. Indeed, they must help. But the critical decisions cannot be cut into separate parts and entrusted permanently to specialists. Eventually, a physician must take the pieces and fit them together to form a coherent plan of action. Only doctors can decide what to do with alternative computer diagnoses after giving due weight to their own observations and impressions. Rarely will a doctor be able to delegate the final decision whether the knowledge to be gained by another test is worth the cost. Physicians will normally know more than anyone else about their patients' condition and thus will be best able to prepare them to make intelligent judgments about alternative treat

ments. Similarly, physicians will often command greater respect than priests or social workers in convincing patients of the steps they need to follow to cure their present disease or avoid future illness.

sum, there is no substitute for doctors who can understand and integrate a range of subjects quite outside the body of bioscientific knowledge. Those who acquire this proficiency will serve their patients, and the public, better. But it is no longer a question of whether physicians choose to respond. The world outside will force them in this direction. Hospital chains and health maintenance organizations are bound to employ an increasing share of the nation's doctors. In a more competitive environment, these organizations will want to hire practitioners trained to gather information economically, to make cost-effective decisions, to motivate patients to comply more willingly with health-preserving regimens. The rising flood of relevant information will compel doctors to use new technological aids. Law courts and newspapers will push ethical issues to the fore, and those who ignore them will be penalized. In today's environment, then, small wonder that medical schools are beginning to think about basic educational reform. The blunt fact is that most of their students today are getting an education that is far too narrow to prepare them for the challenges that await them in their working lives.

The Nature of Reform

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General Goals. Before examining what kinds of changes med-schools might consider, let us remind ourselves of the several aims that educational reform should strive to achieve.

The most obvious goal is to make improvements in medical education that will increase students' ability to serve their patients well after they become doctors. One important way of achieving this aim is to give more attention to neglected areas of knowledge, such as ethics, patient psychology, computer applications, or methods of prevention. But it is also useful to search for better ways to train students to perform traditional tasks. Despite the progress in medical science and technology, many studies have revealed that doctors make a disturbing number of major diagnostic errors. For example, a recent survey of 100 autopsies at a prominent teaching hospital disclosed such mistakes in 22 percent of the cases.24 In almost half of these instances, a correct diagnosis would have indicated a change in the treatment that might have prolonged life. Other studies have shown erratic performance in carrying out routine tasks. Thus, a survey of 249 patients in the outpatient clinic of a teaching hospital revealed that internists often neglected simple high yield procedures such as examining the prostate or asking for a urinalysis (omitted 20 percent of the time), ordering blood sugar analysis (omitted 30 percent of the time), and testing the stool for blood (omitted 40 percent of the time).25 According to the authors, internists who failed to perform these simple high-yield procedures were at the very least unsystematic and at the worst neglectful."26 Training students to be more thorough and more skillful in carrying out such tasks may reduce the number of errors and improve patient care.

Beyond helping students become more proficient, faculties should try to avoid making the educational experience more disagreeable than it needs to be to accomplish -its purposes. At present, medical schools are not pleasant places for all of their students. This much emerges clearly from accounts by students and faculty, alike. After all, what is one to make of the longstanding complaints over the pressures felt by undergraduate premeds and the tedium and frantic memorization associated with the preclinical years? Persistent dissatisfaction on this scale hardly seems inevitable. Nor is it fair to justify the status quo as some sort of test or initiation rite that will strengthen the character of students. On the contrary, there is good reason to look for ways to improve on the present situation, for the time given to medical training takes up years of a human life, years that have a value quite apart from whether a better doctor emerges at the end.

Finally, medical schools must do their best to prepare students to address the problems afflicting our health care system. As we have seen, these problems are serious. In particular, 28

No country believes more strongly in higher education than the United States, and no country is quicker to attribute national problems to failings in our universities.

million people still lack reasonable access to medical services, yet the total bill for health cam in this country is already enormous and continues to climb much faster than the cost of living. No consensus has yet emerged on how to overcome these deficiencies.

We must be careful not to expect too much of medical training in our search for effective solutions. No country believes more strongly in higher education than the United States, and no country is quicker to attribute national problems to failings in our universities. Business schools are blamed for our declining competitiveness abroad, schools of education for the sagging performance of our youth on standard achievement tests, law schools for the surfeit of litigation. In reality, however, the causes are almost always more complex. Medical schools cannot ensure proper care for the millions not covered by existing public and private programs. Nor are they well equipped to prescribe how many doctors the nation needs. No single institution can do much to limit the supply of new physicians or persuade them to work in underserved rural areas. Contrary to popular belief, careful studies even suggest that neither medical school teaching nor the nature of the curriculum has much effect on decisions by students whether to enter primary care as opposed to specialty practice or academic medicine.27 While medical faculties can play a modest supplementary role, only government can devise the policies we need to ensure a proper number and distribution of doctors.

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Medical schools can make more significant contributions along different lines. To begin with, faculties can offer better instruction in preventive medicine. Up to half of all illness in the United States could be avoided through changes in behavior brought about by voluntary adjustments in lifestyle or by preventive measures on the part of government and private organizations. The latter are primarily the responsibility of the state, acting through appropriate rules and incentives. But education and persuasion can bring individuals to avoid smoking, excessive drinking, dietary deficiencies, inadequate exercise, unknowing exposure to health hazards, and many other forms of dangerous behavior In this endeavor, the media and the schools have important roles to play. But physicians have a special competence to discover risks that patients unwittingly run in their daily lives. They also have a special status and authority that can help them persuade individuals to alter their habits. Yet prevention currently receives only 1.5 percent of the total teaching time in the medical curriculum. One should not exaggerate the impact of more instruction - we know too little about the process of changing human behavior. Even so, there

is little doubt that doctors could learn to be more effective in detecting avoidable causes of disease, more competent in using epidemiological techniques to identify community measures for prevention, and more adept at persuading patients to minimize needless risks. With greater numbers of primary care practitioners and the growth of health maintenance organizations and other community-based institutions for health care, the oppor- for doctors to make such contributions seem destined to increase.

Faculties can also prepare physicians to curb inflated costs by eliminating needless medical tests and procedures. Individual practitioners typically make decisions involving diagnosis and treatment that call for expenditures of several hundreds of thousands of dollars each year. One cannot imagine a company in which executives could purchase goods and services in these amounts without knowing the price of what they bought. Yet recent investigations show that a majority of doctors do not know (within 25 percent) what laboratory tests actually cost.28 -Other inquiries have detected enormous variations among similarly situated physicians in the use of laboratory tests and the prescribing of drugs.29 Fortunately, continued efforts to educate about costs seem to produce impressive economies.30 The potential savings are not trivial. Americans spend more than $25 billion each year on drugs and tests. Moreover, according to one presidential commission, unnecessary hospitalization may consume up to 20 percent of all hospital days; 50 to 65 percent of all antibiotics seem unwarranted or incorrectly administered; and billions of dollars are lost each year in useless chest X-rays or pointless respiratory- care treatment and tests. 31

If we are to minimize such excesses, the government must fashion appropriate rules and incentives. But these initiatives will not work well unless physicians understand them and agree to cooperate. The success or failure of many regulations will depend on how they are implemented in hospitals, health maintenance organizations, and clinics, and those who direct these institutions are typically doctors. Moreover, the struggle to control medical costs in a manner consistent with proper care will ultimately be won or lost in a host of separate decisions that practitioners make in treating individual patients. On this bat- the doctor will inevitably have the upper hand. No government inspector, no hospital trustee can readily overrule the judgment of a trained specialist in matters that involve the health and even the survival of human beings.

Finally, although physicians have great influence in treating individual patients, the public will be reluctant to pay the price of allowing everyone to have access to a health care system in which doctors are free to spend whatever they wish. For this reason, if we are ever to guarantee adequate health care to all, we must somehow find a way -of joining the administrator's concern for reasonable cost with the physician's preoccupation with the needs of individual patients. This can hardly occur if doctors know nothing of costs and the problems of organizing and administering the health care system. On the contrary, medical schools must do their utmost to prepare physicians who have the understanding as well as the sensitivity and judgment to reconcile the need to serve the patient with the responsibility to avoid unnecessary expense.

Premedical Education. If reform is to go forward, it should start at the college level, for it is there that students first begin taking courses to advance their medical career. At present, the impact of medical schools on the undergraduate curriculum is, in Lewis Thomas's words, "baleful and malign."32 Some premed students an; competitive to the point of alienating their fellow undergraduates. Many change their courses and extra

curricular activities to suit the supposed demands of medical admissions committees. All face requirements that bias them toward majoring in science and convey the misleading message that medicine, at bottom, is simply a matter of applying scientific knowledge.

In order to address these problems, universities will need, first of all, a change in attitude on the part of both medical schools and faculties of arts and sciences. Medical faculties fail to recognize that their admissions requirements are not simply private matters but policies that significantly affect the under

Medical school requirements are an undesirable intrusion on the college curriculum and should therefore be kept to a bare minimum.

graduate experience. They should acknowledge this fact; accept an obligation to make their influence as benign as s- sible. Arts and sciences professors, because they dislike having students take their courses to fulfill another faculty's requirements, often turn their backs and teach their classes as though the premed requirements did not exist. This practice only makes matters worse, since the required courses come to include much material that cannot be considered truly necessary to the preparation of a doctor.

A useful first step would be for representatives of both faculties to work in concert, first to agree on the minimum of knowl

edge needed to enter medical school and then to devise courses that cover the necessary material. Since students are forced to try to satisfy the requirements of all the schools to which they apply, an even better step would be to launch this effort on a broader basis under the auspices of the Association of American Medical Colleges. Discussions should proceed on the shared assumption that medical school requirements are an undesirable intrusion on the college curriculum and should therefore be kept to a bare minimum. This obligation implies a conscientious attempt to devise premedical courses that do not include mate- irrelevant to becoming a doctor. It also calls for a serious effort by the medical faculty to find space for important subjects in its own curriculum and avoid asking colleges to supply courses that medical schools themselves should offer.

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Although it is hard to know what will come of such an effort, preliminary estimates in our own Faculty of Arts and Sciences suggest that the necessary scientific knowledge might be fitted into two year-long courses. Such compression would cut in half the time presently needed to fulfill the prerequisites for medical school. It would lower the requirements to a level approaching 'the amount of science that should be taken in any event by all undergraduates, whether or not they apply to medical school, as part of a liberal arts education. It would reduce the current pressure to major in science, since students concentrating in other fields could now fulfill their premedical requirements without using up virtually all their undergraduate electives. In these ways, such a modification would significantly lessen the distortions of the premed requirements on the educational choices of college students. *

Another useful step for medical schools would be to cease the practice of expressly basing admissions in part on the applicant's grade average in science courses -- the so-called sci- GPA. Granted, science is -fundamental to medicine, and medical schools can scarcely be indifferent if an applicant does significantly worse in science than in other undergraduate courses. But the current practice conveys a message that science is all important and that the more taken, the better. No amount of verbal reassurance by admissions officers has served to alter this perception. The result is that many undergraduates take more science courses than they might otherwise have chosen in an effort to impress the admissions committees.

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A final possibility would be for college faculties to develop more courses in the humanities and social sciences that involve medicine. Philosophy departments could consider a' course in medical ethics. Economics departments might provide an offering in health care economics. History of science departments could give instruction in the history of medicine. Corresponding offerings are conceivable for departments of sociology, psy- and even political science. Such courses are of interest to a, wide range of students and can be taught in, a manner thoroughly in keeping with a liberal arts education. They offer a broader view of medicine that should help undergraduates make more informed decisions about whether to pursue a medical career. They may also convey. the useful message that medicine is more than science and help aspiring doctors adjust to a world in which their profession will need to cope with a wider set of pressures and concerns.

Furthermore, to echo a host of distinguished critics from Abraham Flexner to Michael Bishop, the most important reason for teaching basic science is not to convey quantities of facts but to instill a set of attitudes that will carry over into clinical practice -- a taste for defining problems, creating hypotheses, and testing them rigorously. What disappoints these critics is that the very effort to cram "all the essential information" into the heads of passive students tends to produce the very opposite of the active, inquiring scientific mind that every physician should possess.

Even if the faculty acknowledges the need for reform, the necessary changes may be long in coming. Professors will find it hard to agree on which concepts and knowledge are truly fundamental and which can be cut away. This is a daunting task under the best of circumstances. It is made more difficult by the fact that many basic scientists have little idea of what a practicing doctor needs to know and regard efforts to reduce the number of lectures they give as a sip of disrespect for their subject. 'Me challenge of mastering new methods of pedagogy is also formidable. Many professors think that they can teach by the discussion method. If one observes them, however, they often do little more than ask true/false questions that test students' memory rather than challenge their powers of reasoning. Instructors are also inclined to give the answer when the correct response does not come quickly from the class, thus depriving

MAY-JUNE 1984 41

students of the valuable experience of struggling through to a conclusion by themselves.

It is no simple matter to prepare a faculty to use new forms of instruction, especially when they have few good models to remember from their own student days. Fortunately, however, much progress has been made in training people to teach. Not only can one find written materials or develop seminars for the purpose; even better ways have been developed through the use of videotape to enable instructors to observe themselves in the act of teaching with the help of an experienced critic. Through these techniques, most people can make surprising progress in perfecting their ability to lead a stimulating discussion. All that remains is to find the motivation and the will-and those are ingredients that must be supplied by leadership backed by adequate rewards.

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The preclinical years are also the time to begin an effort to expand the students' knowledge by introducing subjects such as medical ethics, psychology, statistics, computer use, and formal methods of decision making. We have seen how important these subjects have become in enabling physicians to discharge their responsibilities. Experience also suggests that able teachers can accomplish much to help students acquire competence in these fields. It is certainly possible to train people

Competent instruction using cases and discussion can help students become proficient in perceiving ethical dilemmas when they arise and in thinking about them in a manner that is rigorous and informed.

in the uses of statistics, computers, and formal methods of decision making. As for medical ethics, no one could pretend that a course can turn every aspiring physician into a virtuous human being. Even so, competent instruction using cases and discussion can help students become proficient in perceiving ethical dilemmas when they arise and in thinking about them in a manner that is rigorous and informed. Well-conceived courses can also acquaint students with the causes of rising medical costs and the methods for trying to bring them under control, just as training in cost-benefit analysis and better strategies for acquiring information can help students learn how to minimize unnecessary expense in caring for patients.

The teaching of psychology may present greater difficulty, since so many complexities of human behavior are still beyond our understanding. Even so, students can certainly be taught to talk more clearly and persuasively to patients about medications and treatments. Instructors have likewise shown that they can train students to interview more effectively and to improve their skill in detecting significant psychological and cognitive disorders. At a deeper level, students can also learn the elements of what is known about the impact of psychological and social factors on human illness and rehabilitation, not to mention the effects of personality factors on the willingness of patients to cooperate fully with physicians.

Most faculties already offer courses on almost all these topics. The problem is to assign them their proper place in the curriculum. In the ethos of the contemporary medical school, with its strong emphasis on biomedical science, subjects such as decision analysis, statistics, patient psychology, ethics, and health care policy must be required and given ample time if we expect more than a small minority of students to study them seriously. Faculty members will complain that there is no room

to force these courses into an overstuffed curriculum. Students will resist any inroads on their opportunities to take electives. Yet space can and must be found, whether it comes from elective slots or from the time freed up by pruning unnecessary detail from the basic science courses. After all, many faculties have experimented with a three-year curriculum, and doubts are often expressed at other schools about the value of the final year of study. These straws in the wind suggest that room exists to substitute new material for existing courses if such changes are important to serve the needs of medical practice. The subjects just described surely meet this test. No longer peripheral, they have moved toward the center of our emerging vision of how physicians must think in order to function effectively in the modem world.

Clinical Instruction. The great strength of the clinical years is die vivid reality that comes with learning in the hospital and caring for the sick. Nothing holds students' attention more raptly or motivates them more strongly than the presence of real patients in need of help.

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Yet the very strength of the clinical years is also the source of their greatest problems. Since much of the teaching takes place in the hospital, its content is shaped by the exigencies and peculiarities of patient care. What students learn typically depends on the ailments of the patients who happen to be in the ward at that moment- and in a teaching hospital these ailments are likely to be far more complicated and rare than those that ordinary doctors see in community hospitals and ambulatory settings. The quality of instruction on the ward also reflects the overriding responsibility for patient care. Those who teach, especially the house staff, are often weary from their responsibilities and subject to interruption at any time to serve some compelling patient need.

The principal problems of clinical teaching, then, are rooted in imperatives of care that can easily lead to improvisation and a lack of orderly structure. Adequate structure requires that each rotation have clear objectives fixed in advance to define the basic material and skills that students should master. Adequate structure means that ways are devised and ample time provided to convey the desired material and teach the designated skills within the period of the rotation. Finally, adequate struc- implies that students know the objectives in advance, receive reasonable feedback to monitor their progress, and obtain sufficient evaluation to see whether they achieved the goals prescribed. Too often these qualities are lacking on the wards of our teaching hospitals.

Similar problems are evident in the style of clinical instruction. Walking through hospital corridors, one is struck by the variable, unrehearsed quality of the teaching. Sometimes patients are seen and talked to, sometimes not. Bits and pieces of information are conveyed on the spot as problems develop and new data arrive from the laboratory or the night nurse. Much information is conveyed didactically or demonstrated at the bedside. Instructors do pose questions to students on occasion, but usually to test their knowledge rather than to train their powers of analytic thought. Too rarely does one hear a genuine, sustained dialogue that challenges students to elicit relevant data, venture hypotheses, and move toward a final diagnosis by trial and error. Ethical issues, cost considerations, psychological problems-all pop up occasionally but seldom receive thorough discussion. House staff and faculty specialists are rarely well versed in these subjects and often lack time to discuss them in detail amid the pressing responsibilities of patient care.

of a teaching hospital with its bustle of busy people and its compelling, unpredictable demands. Yet even in this setting, something can be done to achieve greater structure. Senior faculty can set objectives that are understood by all and offer adequate opportunities for feedback and evaluation (as Harvard departments have tried to do in recent years). Required readings and occasional lectures can help ensure that basic information is conveyed and understood.

Although these measures are useful, the tensions inherent in clinical teaching will become more acute as faculties accept the need to broaden their training to place more emphasis on subjects such as ethics, patient psychology, prevention, and cost effective strategies for making diagnoses and prescribing proper treatments. -Many studies have shown that integrating such material into clinical training is essential if these subjects are to make any lasting imprint on the minds and behavior of medical students. But patients who happen to enter the hospital may not have problems that illustrate the topics in optimal fashion, nor will the house staff always have the ability to teach such subjects well. To some extent, these difficulties can be overcome by more readings and seminars and by extending clinical instruction to ambulatory settings that expose students to a broader range of human afflictions. Still better would be some pedagogic method that could serve the needs of order and structure without giving up the vivid realism of actual patient care.

Simulations of various kinds offer useful ways to help surmount this problem. Whether the simulation takes the form of a written script or uses actors who play the part of doctor and patient, students can learn to ask appropriate questions, frame hypotheses and test them until a correct diagnosis can be found. The same method can be transferred to a computer with the great advantage of allowing each student to practice as much as desired at any hour of the day. Better yet, one can program the computer to ask questions of its own in order to form a Socratic dialogue that forces students to think more deeply and devise thorough but efficient strategies for obtaining the data to reach a proper diagnosis. Obviously, simulations -cannot and should not replace the experience of serving and learning on the hospital ward, with its compelling immediacy and reality. As learning technology develops, however, it is not farfetched to assume that such methods will play an increasing role in helping faculties cover a body of important material that is growing too large and diverse to be fully and effectively captured in the hospital setting.

The preceding discussion has revealed something of the scope and range of current opportunities to improve medical education. A team of Harvard faculty and students is now at work devising a new curriculum, or pathway, to capitalize on many of thew possibilities. Although the initial effort will be a pilot venture for only 25 students per year, participating faculty members hope that it will have enough success to exert a strong influence on the entire school.

The original plan was to overcome the arbitrary divisions into premedical, preclinical, and clinical education by having the College agree to an integrated curriculum that students could enter, without taking premedical courses, at the beginning of their junior year. The first two years of the program would have left room for ordinary college courses and might well have been as compatible with a liberal arts education as the experience of a typical premed majoring in science. But the proposal ran into strong opposition. Arts and sciences officials thought it too

professional for the College. Virtually all medical students also protested, as did the medical faculty, fearing that such a program would force undergraduates to make career choices prematurely.

Although this opposition stymied plans to begin the program in the junior year, professors from both faculties are meeting to consider whether the premedical requirements can be reexamined and compressed into two full-year courses. College officials may also agree to highlight courses outside the sciences that involve the health professions and the health care system

so that undergraduates are encouraged to gain a broader view of medicine than the traditional science prerequisites would allow. These reforms would do much to mitigate the problems of premedical education.

In developing a curriculum for the Medical School itself, the principal architects were aware of the tendency in medical education to allow separate departments and disciplines to act in substantial independence from one another. This practice often contributes to a lack of coherence in the curriculum. To guard against this danger, the dean began by assembling a group of faculty members from various departments to devise a set of common goals in the form of a list of attitudes, knowledge, and skills that medical schools should impart to students.

A, striking aspect of the list is the emphasis placed on the development of proper attitudes. As one would expect, many of the attitudes are hardy perennials: honesty, integrity, dependability, sensitivity, responsibility. But others are not so obvious: "capacity to be with the sick and suffering and remain open to their needs"; "recognition of one's own limitations"; "recognition of how financial aspects of practice affect self, patients and society"; "recognition of the impact of power on self, patients and co-workers."

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It is hard to think of another professional faculty, with the possible exception of theology, that would explicitly set about to nurture such attributes in its students. In part, the effort to do so may simply be a reflection of the awesome responsibilities of a profession that is often called upon to make decisions involving life and death. In part, the effort may be a response to signs of growing dissatisfaction over the quality of the personal interaction between doctors and their patients and coworkers. (For example, a study described in the recent Institute of Medicine report on medical education found that 64 percent of a large sample of families were unhappy with their doctorpatient relationship and that one-third to one-half of the families had changed doctors because of dissatisfaction over the physician's personal quahties.)35 Whatever the reason, the desire to address these issues is commendable. The problem lies in figuring out just how the task can be accomplished.

Good teaching will undoubtedly achieve something. A skillful instructor can raise a student's consciousness, awaken interest, stimulate thought. But if the faculty is serious about nur- attitudes, there remains much truth in Plato's observation: "If you would know virtue, observe the virtuous am." Any effort to teach by personal example, however, raises interesting problems of its own. Will instructors be chosen with an eye to

(continued on page 70)

NEEDED: A new way to train doctors
(continued from page 43)

their character and a concern for the extent to which they manifest the attitudes they seek to plant in their students? If so, the selection of faculty will call for delicate judgments that few people can successfully make and fewer still will accept with confidence. Without choosing teachers on this basis, however, one wonders how much the Medical School can accomplish in carrying out its laudable aims.*

Turning to areas of knowledge that the new curriculum will convey, one finds, at the top of the list, "an understanding of the central physical, chemical and biological principles and mechanisms that underlie human health and disease, including awareness of the natural history and manifestations of the diseases." The prominence given these traditional subjects should help to dispel any suspicion that the new curriculum is rejecting the centrality of science or training a special breed of doctors who will somehow escape the need to be thoroughly versed in biomedical knowledge. At the same time, the planning group goes on to specify a number of other goals that have been stressed in this report:

-- To understand the emotional, psychological and cultural underpinnings of human behavior, including the interweaving of mind and body in illness and health ...

-- To know the financial and organizational aspects of health care ...

-- To understand the various factors which contribute to the prevention of illness ...

--  An understanding of the statistical and probabilistic aspects of human biology and clinical medicine ...

The list of skills likewise reflects a desire to build the broader competence that physicians increasingly need. The planning group puts emphasis not only on obtaining information from printed material but on retrieving it from computers. Statistical and problem-solving skills will get particular attention in order to foster greater competence in acquiring relevant information, assessing its validity, and making sound probabilistic judgments. Discussions about the selection of appropriate diagnostic technology will be accompanied by explicit attempts to assess the costs and benefits involved.

In addition to these competences, the planning group has also listed the mom familiar skills of listening, observing, interviewing, and communicating effectively. These tasks are always honored in principle but often slighted in practice, so much so that investigators have reported that medical students' ability to communicate actually deteriorates during their professional Yet communication is bound to take on greater importance in the future as doctors allow their patients to participate mom in deciding what chances to take with different tests and remedies and as higher priority is placed on motivating patients to follow treatments conscientiously and to avoid various kinds of life-threatening behavior. With such needs, one can only hope that the deliberate inclusion of these skills among the aims of the new curriculum presages an equally deliberate effort to teach them systematically.

Some readers may believe that medical schools can best ensure proper attitudes by taking greater care in selecting students. In fact, most medical schools do interview applicants and try to give weight to traits of character such as those listed by the planning group. While these efforts are. commendable, their impact is unclear. The interviewing process is sufficiently unreliable and the traits involved sufficiently intangible and easy to simulate that we have no reliable evidence that such procedures can have much effect on the characteristics of a medical school student body

70 HARVARD
MAGAZINE

whatever its ultimate success, no one can fault the new Pathway for having stunted ambitions. After reex- almost every accepted premise about medical education, the participants seem committed to comprehensive change. Amid the details of innumerable planning memoranda, several themes stand out with special clarity. To begin with, the curriculum calls for a radical shift in teaching technique. Lectures will be cut to one hour per day in order to stress active discussion rather than the passive modes of learning so roundly criticized in the past. A strong emphasis on problem solving and independent study will help to overcome the static quality of medical education and to impart the capacity for continued learning that is needed to keep up with such a vast and rapidly changing body of knowledge. Properly executed, these changes should train students better and make their education much more stimulating.

In carrying out its work, the planning group has likewise acknowledged the forces that are currently working to broaden the physician's role and has reserved ample time in the curriculum to prepare students to cope with these new challenges. If the faculty can translate this time into effective instruction, students should receive an education that prepares them not only. to serve their patients better but also to respond more effectively to societal needs.

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Finally, participating faculty have sought to integrate the curriculum with the help of working groups that include professors from several different departments. By this device, scientists and clinical faculty can work together to break down the separation between the preclinical and clinical years. Through these efforts, the planners hope to bring out more clearly the relevance of basic science by stressing its links to clinical prob- Conversely, subjects such as statistics, cost containment, Patient Psychology, and prevention will not be treated merely in isolated courses but will reappear in the clinic where students can deepen their understanding of these important topics by discussing applications to real cases.

At this early stage. many questions remain unanswered. Who will teach some Of the new material in decision making, ethics Patient Psychology, and the like, for which qualified professors

are in short Supply? What steps will the faculty take to ensure that students actually learn these subjects? How will instructors manage to change their teaching styles and master the art of leading a genuine discussion? Will the rest of the faculty allow the use of rewards and recognition sufficient to induce professors to plunge wholeheartedly into this teaching effort? What will participants do to escape the tyranny of the National Boards with their emphasis on rote memory and factual detail? And how can the school evaluate the program convincingly when the criteria are necessarily vague and the skeptics quick to ascribe any student enthusiasm to the "Hawthorne effect" that tends to accompany any experiment conducted with a small group?

These are typical questions to arise in the development of a major educational innovation. They call for care in pl 9 and execution but not for discouragement of any kind. The *essential point is that the dean and a large group of faculty have recognized that basic changes are needed in medical education and are prepared to devote the time required to produce the necessary reforms. This is an event of great importance for the University and deserves our strongest encouragement and support.

Notes

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1. Charles P. Friedman and Elizabeth F. Purcell, eds., The New Biology and Medical Education: Merging the Biological, Information, and Cognitive Sciences (New York: Josiah Macy, Jr. Foundation, 1983).

2. Institute of Medicine, Medical Education and Societal Needs: A Planning Report for the Health Professions (Publication No. IOM-83-02, July 1983).

6. Julius Richmond and Milton Kotelchuk, "Ile Effect of the Political Process on the Delivery of Health Services" (Unpublished paper, 1982), 18.

7. John Wills, Lewis Garrison, and Itzhak Jacoby, Modeling, Research, and Data Technical Panel, Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, vol. 2 (1980).

8. Institute of Medicine, A Manpower Policy for Primary
Health
Care: Report of a Study (Publication No. IOM-78-02, 1978).

9. Although the study has not been released, these findings were described by the principal investigator, C. Hess Haagen, of Wesleyan University, and were reported in the Boston Herald, March 2, 1983. Ile study involved 1 .064 students at Amherst, Bow- Swarthmore, Haverford, Williams, and Middlebury Colleges and Wesleyan University.

Frederick Sierles, Ingrid Hendricks, and Sybil Circle, "Cheating in Medical School:' Journal of Medical Education 55 (1980), 124-25. The study involved a survey of 400 students at the Stritch School of Medicine, Loyola University in Chicago, and the University of Health Sciences at Chicago Medical School.

11. A more scathing critique has been delivered by a distinguished scientist, J. Michael Bishop, who teaches basic science at the Medical School at the University of California, San Francisco. "What emerges are physicians without inquiring minds, physicians who bring to the bedside not curiosity and a desire to understand, but a set of reflexes that allows them to earn a handsome living." Speech delivered to the annual meeting of the American Association of Medical Colleges, Nov. 8. 1983.

12. Fritz Jules Roethlisberger, The Elusive Phenomena: An Autobiographical Account of My Work in the Field of Organizational Behavior at the Harvard Business School (Boston: Division of Research, Harvard Graduate School of Business Administration, 1977).

13. Quoted by Barbara Filner, Victoria Weisfeld, and Dolores Patron, "Infusion of New Fields into Medical Education," Medical Education and Societal Needs (IOM, 1983), 148.

Of Computer Data Base Systems," Journal of the American Medical Association, 249 (1983), 1610.

15. See e.g., Donald M. Berwick, Harvey V. Fineberg, and Milton C. Weinstein, "When Doctors Meet Numbers," American Journal of Medicine, 71 (1981), 991.

16. These findings are taken from unpublished reports submitted to
the Planning Group for the new pathway.

17. Steven A. Cohen-Cole, "On Teaching the New (and Old) Psychobiology," in New Biology and Medical Education, ed. Fried- and Purcell (1983), 133-34.

18. M. Robin DiMatteo and Howard F. FTiedman, Social Psychology and Medicine (Cambridge, MA: Oelgeschlager, Gunn and Hain, 1982), 106.

19. On angina, see Jack H. Medalie and Uri Goldbourt, "Angina Plectoris Among 10,000 Men," American Journal of Medicine, 60 (1976), 910. On the effects of grief, see R. W. Bartrop et al., "Depressed Lymphocyte Function After Bereavement," Lancet 1 (1977), 834.

20. See e.g., Ellen J. Langer, Irving L. Janis, and John A. Wolfer, "Reduction of Psychological Sam in Surgical Patients." Jour- of Experimental Social Psychology, 11 (1975), 155.

21. See e.g., Barbara S. Hulka et al., "Communication, Compliance and Concordance Between Physicians and Patients with Prescribed Medications," American Journal of Public Health, 66 (1976), 847. See also, Di Matteo and Friedman, Social Psychology and Medicine (1982), 40, 48, 49, 82.

22. See Lewin, "Group Decision and Social Change" in Readings in Social Psychology, ed. Maccoby, Newcomb, and Hartley (1958); see also Bass and Wilson, "The Pediatrician's Influence in Private Practice, Measured by a Controlled Seat Belt Study," Pediatrics, 33 (1964), 700.

23. For a detailed consideration of this shift and its implications for medical practice, see Harold Bursztajn et al., Medical Choices, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty (New York: Delacorte Press, 1981).

24. Lee Goldman et al., "The Value of the Autopsy in Three
Medical
Eras," New England Journal of Medicine 308 (1983), 1000.

25. Edward J. Goetz. et al., "Quality of Diagnostic Examinations in a University Hospital Outpatient Clinic," Annals of Internal Medicine 78 (1983), 481.

27. Daniel H. Funkenstein, "The Prediction of the Career Choices of Students at Graduation from Data Collected on Them at Admission and Matriculation to Medical School, 1958-1974," Unpublished paper on file at the President's Office, Harvard University. Dr. Funkenstein's study suggests that career decisions were affected primarily by changes in social ideology outside the medical school and by changes in funding patterns affecting the remuneration available for different types of careers. Since changes in career choice throughout this period tended to occur simultaneously among students at different stages in their train- Dr. Funkenstein concludes that the nature of the training itself does not seem to have been a significant factor.

29. Steven A. Schroeder et al., "Use of Laboratory Tests and Pharmaceuticals -- Variation Among Physicians and Effect of Cost Audit on Subsequent Use," Journal of American Medical Association 225 (1973), 969.

30. Ibid., See also Robert S. Lawrence, "The Role of Physician Education in Cost Containment," Journal of Medical Education 54 (1979), 841.

31. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Securing Access to Health Care: A Report on the Ethical Implications of Difirerences in the Availability of Health Services (1983), 186-88.

34. See e.g., Jill H. Larkin, "Learning and Using Large Amounts of Knowledge: The Role of Basic Science;' in New Biology and Medical Education, ed. Friedman and Purcell (1983), 185, 188.

35. Stephen J. Williams, Mena D. Nightingale, and Barbara Filner, "The Physician's Role in a Changing Health Care System," Medical Education and Societal Needs (IOM, 1983), 70, 93.

36. See G. P. Maguire and D. R. Rutter, "Training Medical Students to Communicate" in Communications Between Doctors and Patients, ed. A. E. Bennett (1976).

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PROGRAMS IN THE HISTORY OF MEDICINE & MEDICAL ETHICS

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History of Medicine and Medical Ethics (including the Division of Medical Ethics)

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The Harvard Program in the History of Medicine is an interfaculty program jointly sponsored by the Harvard Medical School and the Faculty of Arts and Sciences (FAS). At Harvard Medical School, teaching and research is based in the Department of Social Medicine, an interdisciplinary department in the medical humanities and social sciences. At FAS, the program is based in the Department of the History of Science, a department offering an undergraduate concentration and graduate programs leading to the Ph.D.

The program has a strong commitment to teaching and research that places the development of medical knowledge and practice into broad social and cultural contexts. In recent years, the field of the history of medicine has undergone an important transformation. Although study of the development of scientific and medical knowledge remains crucial to the field, studies have increasingly attempted to assess the changing nature of scientific and medical practices, the experiences of health and illness, as well as the history of health policies. These interests are strongly reflected in the research and teaching aspects of the Program. At the core of the Program's agenda are studies of how medicine and science evolve from--and are reincorporated into--a wider social and cultural context; how health care inevitably leads to complex moral, ethical, and policy issues; and how the determinants of health and disease are revealed through investigations into the social and scientific responses to both epidemic and chronic disease. A principal tenet of the approach fostered in the Program is that historical scholarship may assist in a more sophisticated understanding of a wide array of questions and dilemmas in contemporary medicine and science.

 

The doctoral program in the history of medicine is among the most active in the United States. In addition to training Ph.D.s, the program has successfully recruited a number of physicians and medical students to do a combined M.D./Ph.D. Students in the Program work on a wide array of historical issues. Further, doctoral candidates participate actively in the undergraduate teaching programs.

Teaching Programs

The Harvard Program in the History of Medicine conducts a vigorous educational curriculum at all levels of the University. The Program has established an especially strong medical history curriculum for Harvard undergraduates in the honors concentration, History and Science. Students in this program spend three years in a structured tutorial program, culminating in the writing of an original senior honors thesis in the history of medicine and science. Currently more than 150 Harvard students are enrolled in the program. The Program reaches a large number of non-concentrators as well; more than 350 undergraduates are currently enrolled in the Core Curriculum course, "Medicine and Society in America."

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The Medical Division of Medical Ethics (DME)

 

The DME, committed to forging links between the medical school and the larger community (as well as among Harvard's hospitals, schools and related programs), is dedicated to improving medical care and medical education by building greater awareness and understanding of the critical moral, ethical, and social dimensions of medicine. The DME applies a broad interdisciplinary approach to investigate how social, cultural, and political forces shape ethical considerations in the sciences and medicine. The Division brings together the social sciences and humanities with research science and clinical medicine to explore critical moral elements of the social determinants of health and disease, the nature and meaning of illness, and the organization and delivery of health care.

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As part of Division's commitment to broad public involvement and perspective, the Division is dedicated to intensive empirical and theoretical investigations into how medical care is organized and delivered, both on a clinical and policy level. In all of DME's teaching and research, The Division emphasizes the importance of understanding complex ethical dilemmas in their social, cultural, economic, and political contexts.

The Past, Present & Future Possibilities

 

The DME was part of President Derek Bok's university-wide commitment, a decade ago, to ethics education. As part of that commitment, the DME integrates ethical reflection into the rigors of medical education. That vision is being expanded today - reaching beyond the University to involve the larger community in discussions of ethical issues. In the decade ahead, the Division's crucial task will be to sharpen its understanding and ability to negotiate a series of enormously complex moral dilemmas raised by medicine and science; and, in addition, bring a wide range of clinical, social science and humanistic disciplines to its investigation/s. The Division hopes to create new possibilities to enhance its collective ability to conduct science with integrity and deliver effective care with compassion.

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Medical Ethics and Medical Ethics' Fellowships (1998-1999)

 

The Division of Medical Ethics (DME) at HMS encourages teaching and research on ethical issues in medicine. Its Fellowships are open to physicians with a serious academic interest in medical ethics. Non-physicians in academic fields related to medicine are also invited to apply. Fellows participate in the intellectual life of the DME. They attend seminars & tutorials designed to introduce them to a wide range of issues in medical ethics. They have access to various professional schools and programs at Harvard, including training in clinical epidemiology at HSPH (Harvard School of Public Health). Fellows conduct original research in ethics and are encouraged to develop their teaching skills in ethics and related disciplines.

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Fellows are expected to have external salary support (e.g., from a training program grant or a sponsoring institution). The Division provides support for other academic needs. Fellows are selected on the basis of their previous academic achievement and the contribution they are likely to make as teachers and researchers in medical ethics.

 

Applicants should submit a curriculum vitae and brief statement (not more than 1000 words) describing their interest in ethics and plans for using the Fellowship. Applicants should also indicate the nature of their salary support and provide a list of three persons who will submit letters of reference. For Fellowships beginning September 1999, the deadline for application submission of materials: MARCH 1999. Four (4) copies of all application materials should be sent to Janet Levoff, DME, HMS, 641 Huntington Ave., 4th Floor, Boston, MA 02115; (617) 432-3041.

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© Harvard Medical School - Last updated Summer 1998

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Volume 23 - Number 12 October 1998 Editor-in-Chief Stephen E. Goldfinger, M.D. Editor Leah R. Garnett

Clearing Up Confusion About Hypertension Drugs

It’s hard not to be perplexed about high blood pressure drugs. There are currently more than 50 antihypertensive agents on the market and more than 25 additional preparations that combine two or more medications. Many of the newer drugs have a slightly different chemical structure from that of older ones but produce similar effects; others act in entirely new ways.

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But as one recent incident has illustrated and at least one report points out: new is not necessarily better, and sometimes it can be worse.

• On June 8, 1998, a year after the drug mibefradil (Posicor), a calcium channel blocker, was approved by the U.S. Food and Drug Administration (FDA), it was withdrawn from the market because of potentially dangerous drug interactions.

• On June 10, 1998, a report by a Yale researcher, published in the Journal of the American Medical Association (JAMA), pointed out that although national guidelines call for the use of thiazide diuretics as one of the initial drugs for the treatment of hypertension, doctors have been prescribing these agents less and less over the past 15 years, in part because of extensive promotion by pharmaceutical companies of newer, more costly medications.

• And on June 17, 1998, an analysis of 10 clinical trials, published in JAMA and conducted by researchers from the Ochsner Clinic in New Orleans, indicated that beta-blockers, a class of widely used hypertension drugs (atenolol, propranolol), provided no benefit in preventing first heart attacks or improving the survival of people age 60 and over. Although this supports the most recent national hypertension guidelines — which, for the first time, recommend that diuretics, not beta-blockers, be used as the first-line therapy for older people — thousands of older Americans with high blood pressure take beta-blockers without a diuretic or other antihypertensive agent.

Until recently, about 200,000 people in the United States relied on Posicor to reduce their blood pressure. A new type of calcium channel blocker, it was thought to have some possible advantages over existing ones, but this was overshadowed by Posicor’s potential for causing harmful interactions with other drugs.

Indeed, the FDA instructed Roche Laboratories, Posicor’s manufacturer, to warn doctors that three common medications — two allergy drugs and a heartburn treatment — should not be used with the calcium blocker because the combination could lower the heart rate precipitously. Posicor inhibits the activity of certain enzymes in the liver that enable the body to break down and eliminate other medications. This effect causes certain drugs to build up to potentially dangerous levels. Last fall, the FDA added warnings against taking Posicor with other widely used medicines, including some cholesterol-lowering drugs and antibiotics. By the time Posicor was pulled from store shelves in June, more than 25 medications were reported to have caused adverse reactions when taken with the drug.

By now, doctors should have switched their patients from Posicor to another antihypertensive agent. If your physician has not done this, don’t stop taking the drug on your own because uncontrolled hypertension can have more serious consequences than the medication. But talk to your doctor immediately about switching to another blood pressure drug and ask if there is a waiting period. Four people went into shock (dangerously low blood pressure) and one of them died when doctors switched them from Posicor to another calcium channel blocker too quickly. As a result, on June 12, 1998, Roche issued the following warning to doctors: wait 7 – 14 days before prescribing another calcium channel blocker (diltiazem, felodipine, nifedipine, verapamil) or a beta-blocker to allow Posicor to be “washed out” of the system. There is no waiting period to begin ACE inhibitors, angiotensin-II antagonists, and diuretics.

Introduced in the 1950s, diuretics are the oldest class of drugs used to treat hypertension. They help the kidneys eliminate sodium and water from the body; this decreases blood volume, which in turn lowers blood pressure. Diuretics are especially effective for people with salt-sensitive hypertension (African-Americans are more sensitive to salt than Caucasians) and those with isolated systolic hypertension, who are generally over 60. In this form of the disease, it is only the systolic (upper) reading that is elevated. The systolic number measures arterial pressure during the heart’s pumping phase; the (lower) diastolic reading represents the pressure during the resting phase between heartbeats. Hypertension is generally defined as a systolic reading of 140 mm Hg or higher and/or a diastolic reading of 90 mm Hg or greater.

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In the June 10 JAMA report, Yale cardiologist Marvin Moser noted that the heavy marketing to physicians of newer, more expensive drugs by pharmaceutical companies, coupled with misconceptions about the adverse effects of diuretics, are largely responsible for the decline in their use. This is disconcerting, given that diuretics have, for years, shown up as one of the preferred treatments for hypertension in the recommendations of the Joint National Committee (JNC) on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. (See Harvard Health Letter, January 1998.)

Dr. Moser writes that concerns about the possible side effects of diuretics, such as raising cholesterol, are exaggerated, and that with the small doses that are now generally used, these effects are minimal. In addition, there is a large body of research demonstrating that diuretics prevent heart attacks, heart failure, and strokes. Although diuretics are one of the recommended first-choice treatments, this does not mean that the newer agents are not valuable as well; indeed, the most effective treatment for some people with hypertension is a diuretic combined with a small dose of another agent, such as a beta-blocker, ACE inhibitor, or calcium channel blocker.

November 1997 marked the first time that the JNC stopped recommending beta-blockers used alone as the initial antihypertensive treatment for older people. Instead, the panel said, people over 60 should be given diuretics before trying other drug combinations. Although beta-blockers are proven lifesavers for people who have had heart attacks, regardless of their age, and when combined with diuretics in many individuals, there is no evidence that their use as a single therapy in older hypertensive patients reduces mortality compared to a placebo, according to the June 17, 1998, analysis in JAMA of 10 clinical trials involving more than 16,000 individuals age 60 and older.

People should not assume that beta-blockers are inappropriate for them without discussing their pros and cons with a physician. Unfortunately, however, some doctors are nearly as confused as their patients when it comes to understanding hypertension drugs. In a survey of 240 primary care physicians, 29% were not familiar with the current JNC guidelines. (For the latest guidelines, go to the National Heart, Lung, and Blood Institute’s Web site at www.nhlbi.nih.gov.)

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Abstract

The study of Nutrition has been designated as a curricular theme to be developed throughout the entire four year curriculum at Harvard Medical School, rather than being limited to one or two discrete courses. An advisory committee of faculty, students and medical educators meet regularly to establish curriculum goals, analyze existing medical school nutrition curriculum, develop nutrition resources and materials for both faculty and students to promote learning and awareness of the importance of nutrition in health.

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For more information on this theme, please contact:

Clifford W. Lo, Sc.D., M.D.

Assistant Professor in Pediatrics

Children's Hospital

Gastroenterology

300 Longwood Avenue

Boston, MA 02115

Phone: 617-355-7612

lo@a1.tch.harvard.edu

W. Allan Walker, M.D.

Conrad Taff Professor of Nutrition & Pediatrics

Mass General East

GI/Nutrition Lab

Room 3401

Charlestown, MA 02129

Phone: 617-355-6006

Fax: 617-726-4172

walker@helix.mgh.harvard.edu

Click here for a listing of Harvard Faculty & Staff Involved in
Nutrition Related Research & Teaching

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Date last updated: 12/10/98
Author: Roberta Koffman
Web Developer: Ryan Pronovost
Office of Educational Development

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HARVARD MEDICAL SCHOOL
NUTRITION OBJECTIVES & CURRICULUM

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YEAR I OBJECTIVES

1. Describe the absorption and metabolism of the major nutrients--carbohydrates, proteins, and fats--in health and disease.

2. Recognize the functions, relationships and deficiency syndromes of the essential minerals and vitamins.

especially:		also:
Calcium	Vitamin K	Sodium	Selenium
Iron	Vitamin C	Potassium	Fluoride
Vitamin A	Vitamin B6	Chloride	Iodine
Vitamin D	Vitamin B12	Phosphorus	Thiamin
Vitamin E	Folate	Magnesium	Riboflavin
		Zinc
		Copper

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YEAR II OBJECTIVES

3. Assess nutritional status by simple anthropometric (height and weight), dietary, clinical and laboratory means. This includes taking a diet history by recall, food record, or food frequency, and knowing some methods of determining body composition.

4. Discuss the epidemiology, prevention, diagnosis and treatment of the major nutritional diseases in the world, including:

Obesity	Anemia
Protein-Calorie Malnutrition	Cancer
Atherosclerosis	Diabetes
Eating Disorders	Osteoporosis

5. Determine energy and nutrient requirements for individuals including premature and term neonates, infants, children, adolescents, pregnant and lactating women, adult men and women, postmenopausal women, and the elderly. This includes general knowledge of the use of RDA's, Harris-Benedict equations and indirect calorimetry.

6. Give general dietary guidelines for Americans and be able to give patients specific nutritional recommendations or be able to find appropriate nutritional resources for referral, such as dietitians, nutrition literature, and books.

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YEAR III and IV OBJECTIVES

7. Evaluate nutritional status and appropriately prescribe enteral and parenteral nutritional therapy in various major diseases including:

Cancer

Heart Disease

Renal Disease

Cystic Fibrosis and other respiratory disease

AIDS

Neurological Disease

Gastrointestinal and Liver Disease

8. Monitor growth and diet of infants, children, and pregnant women, and provide counseling on nutritional issues including:

Breastfeeding and introduction of infant formulas, solids, and cow's milk;

Iron, fluoride, calcium and folate supplementation;

Physical activity and exercise

Obesity, failure to thrive and eating disorders

9. Recognize nutritional problems and provide basic nutrition counseling in patients seen for routine health maintenance and chronic medical problems, including those with:

Obesity

Hypertension

Diabetes

Alcoholism

10. Read critically and be able to discuss nutritional scientific literature

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You can reach Vibrant Life in many ways, including by mail to Vibrant Life, 2808 N. Naomi St., Burbank, CA 91504.  Within the US and Canada, use the toll free number:  (800) 523-4521, the local number:  (818) 558-1799, the FAX:  (818) 558-7299, eMail to kimberly@oralchelation.com or any one of the hundreds of message forms throughout the 50 web sites.  Vibrant Life normally ships the same day we get an order.  There are message forms on each of the 100,000+ pages on this and other sites where you can communicate with Vibrant Life.  Check out our companion site, at:  http://www.oralchelation.net where Karl's 2000 page book is published.  Karl Loren is the author and webmaster for this BOOK, as well as for another web site about ORAL CHELATION.  His personal philosophical articles are at PHILOSOPHY. 

Copyright © May 20, 2008 6:26 AM by Karl Loren on behalf of Vibrant Life, ALL RIGHTS RESERVED.  Permission is granted for non-commercial downloading, copying, distribution or redistribution on two conditions:  One, that some form of copyright notice is included in every copy distributed or copied, showing the copyright belonging to Vibrant Life, Burbank, CA, at www.oralchelation.com . The second condition is that the material is not to be used for any purpose contrary to the purposes and objectives of this site.  This permission does not extend to materials on this site which are copyrighted by others.

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You can reach Vibrant Life in many ways, including by mail to Vibrant Life, 2808 N. Naomi St., Burbank, CA 91504.  Within the US and Canada, use the toll free number:  (800) 523-4521, the local number:  (818) 558-1799, the FAX:  (818) 558-7299, eMail to kimberly@oralchelation.com or any one of the hundreds of message forms throughout the 50 web sites.  Vibrant Life normally ships the same day we get an order.  There are message forms on each of the 100,000+ pages on this and other sites where you can communicate with Vibrant Life.  Check out our companion site, at:  http://www.oralchelation.net where Karl's 2000 page book is published.  Karl Loren is the author and webmaster for this BOOK, as well as for another web site about ORAL CHELATION.  His personal philosophical articles are at PHILOSOPHY. 

Copyright © May 20, 2008 6:26 AM by Karl Loren on behalf of Vibrant Life, ALL RIGHTS RESERVED.  Permission is granted for non-commercial downloading, copying, distribution or redistribution on two conditions:  One, that some form of copyright notice is included in every copy distributed or copied, showing the copyright belonging to Vibrant Life, Burbank, CA, at www.oralchelation.com . The second condition is that the material is not to be used for any purpose contrary to the purposes and objectives of this site.  This permission does not extend to materials on this site which are copyrighted by others.

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You can reach Vibrant Life in many ways, including by mail to Vibrant Life, 2808 N. Naomi St., Burbank, CA 91504.  Within the US and Canada, use the toll free number:  (800) 523-4521, the local number:  (818) 558-1799, the FAX:  (818) 558-7299, eMail to kimberly@oralchelation.com or any one of the hundreds of message forms throughout the 50 web sites.  Vibrant Life normally ships the same day we get an order.  There are message forms on each of the 100,000+ pages on this and other sites where you can communicate with Vibrant Life.  Check out our companion site, at:  http://www.oralchelation.net where Karl's 2000 page book is published.  Karl Loren is the author and webmaster for this BOOK, as well as for another web site about ORAL CHELATION.  His personal philosophical articles are at PHILOSOPHY. 

Copyright © May 20, 2008 6:26 AM by Karl Loren on behalf of Vibrant Life, ALL RIGHTS RESERVED.  Permission is granted for non-commercial downloading, copying, distribution or redistribution on two conditions:  One, that some form of copyright notice is included in every copy distributed or copied, showing the copyright belonging to Vibrant Life, Burbank, CA, at www.oralchelation.com . The second condition is that the material is not to be used for any purpose contrary to the purposes and objectives of this site.  This permission does not extend to materials on this site which are copyrighted by others.

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Dear Karl,

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Click here to add the Wednesday Letter as a Channel on your desktop.   If your browser is so-equipped, you will be guided through a series of simple questions (about subscription information).  Depending on your choices you can show the Vibrant Life Wednesday Letter as one of your "active channels" which will automatically download the new Wednesday Letter every month.  In this way you can have the Wednesday Letter delivered to your desktop during the night (or your schedule) for immediate viewing in your browser.  You can turn on or off this channel, at will, and delete the channel from your desktop at any time.  With this feature operating you can click on the Wednesday Letter channel at any time to read the most recent copy of this electronic letter.

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You can reach Vibrant Life in many ways, including by mail to Vibrant Life, 2808 N. Naomi St., Burbank, CA 91504.  Within the US and Canada, use the toll free number:  (800) 523-4521, the local number:  (818) 558-1799, the FAX:  (818) 558-7299, eMail to kimberly@oralchelation.com or any one of the hundreds of message forms throughout the 50 web sites.  Vibrant Life normally ships the same day we get an order.  There are message forms on each of the 100,000+ pages on this and other sites where you can communicate with Vibrant Life.  Check out our companion site, at:  http://www.oralchelation.net where Karl's 2000 page book is published.  Karl Loren is the author and webmaster for this BOOK, as well as for another web site about ORAL CHELATION.  His personal philosophical articles are at PHILOSOPHY. 

Copyright © May 20, 2008 6:26 AM by Karl Loren on behalf of Vibrant Life, ALL RIGHTS RESERVED.  Permission is granted for non-commercial downloading, copying, distribution or redistribution on two conditions:  One, that some form of copyright notice is included in every copy distributed or copied, showing the copyright belonging to Vibrant Life, Burbank, CA, at www.oralchelation.com . The second condition is that the material is not to be used for any purpose contrary to the purposes and objectives of this site.  This permission does not extend to materials on this site which are copyrighted by others.