On May 29, 2005, 73 men and women received the Doctor of Medicine degree from Brown University representing the 31st class of physicians graduated from that institution since 1975. Of the 2312 physician graduates of previous classes, approximately 416 (18%) are currently licensed to practice in Rhode Island.

The purpose of this article is to introduce the graduates of the MD Class of 2005 to the physician community in Rhode Island, as many will be your future professional colleagues.

Thirty-four graduates were men (47%) and 39 were women (53%). The racial/ethnic composition of the class, as shown in Table 1, shows a lower proportion of students from CaucasianAmerican backgrounds (42%) than the previous year (45%). Nineteen percent of the graduates are members of minority groups underrepresented in medicine (10 African Americans, and 4 Mexican American) as defined by the Association of American Medical Colleges (AAMC). This number is higher than the 9.2% underrepresented minorities (URM) reported for last year’s graduates. The proportion of URM students among all four years of Brown medical students is 19%.

Nine graduates are residents of Rhode Island. The Rhode Island students in this year’s graduating class came from eight different communities in the state, with two students from Providence, and one student each from Bradford, E. Greenwich, E. Providence, Newport, Portsmouth, Riverside, and Westerly. The high schools from which the students graduated also reflect this diversity, with students having attended Classical, Claremont, E. Greenwich, Rogers, St. Mary Academy-Bayview, St. Paul’s, and Westerly high schools.

The largest proportion of students in the MD Class of 2005 comes from the Program in Liberal Medical Education (PLME), with 41 such graduates (56%) having come through that route. The second largest cohort of students (12 graduates) came through the combined Brown-Dartmouth Medical Education Program in which students spend their first two years of medical school at Dartmouth, then transfer to Brown for the final two years.

The medical school entered into special agreements with postbaccalaureate premedical programs at Bryn Mawr College and Columbia University shortly after the PLME was inaugurated. Students from these programs decided upon a career in medicine only after completing college. Typically, they have been engaged in other careers for several years following college. The goals in establishing this new route of admission were to maintain a rich diversity in the student body by admitting students who were older and who had different academic and life experiences as well as rounding out the total class size to compensate for the expected attrition from the PLME. Six members (8%) of the class were postbaccalaureate students, three from Bryn Mawr College and three from Columbia University.

Among the remainder of the class, six students were part of the Early Identification Program (EIP), three from Tougaloo College, two from Providence College, and one student from University of Rhode Island. EIP students are offered provisional admission to the medical school during their sophomore year at their respective undergraduate colleges. Of the remaining graduates, three entered medical school through the MD/PhD program, two through the Brown Avenue (current or former Brown students who were not in the PLME), and three through advanced transfer.

Brown University was the most common undergraduate college among the graduates accounting for 44 graduates. Tougaloo College came second with three members, followed by Haverford College, Providence College, and University of California Berkeley each with two members from the Class of 2005.

The most common undergraduate major (56%) among the class members was biology (including subdisciplines such as biochemistry, neural sciences, and microbiology). Science majors taken together (including psychology) accounted for 72% of all majors, while 18% of majors were in the humanities and 12% in the social sciences. Among the humanities majors, English was the most common choice, while community health was the most popular choice among those majoring in the social sciences. Nine students double majored.

WHERE THEY ARE GOING

Internal medicine remained the most frequently selected specialty, with 32 students selecting that specialty, and family medicine came in second place with 7 graduates choosing that specialty. Table 2 lists the number of students selecting different types of residency programs.

The proportion of the class entering specialties in primary care fell to 44% this year, continuing a 4-year slide. This includes the fields of internal medicine, pediatrics, family practice, medicine/pediatrics, and obstetrics and gynecology. Figure 1 illustrates the specialty choices of the Class of 2005.

The actual number of graduates who will eventually practice primary care after completing their graduate medical education will be smaller than the 44% reported here. Based on previous data from the AAMC that tracked graduates, approximately 22 graduates (30%) will actually practice primary care.

Medical schools around the world are moving from the traditional discipline-oriented curriculum toward an integrated curriculum. The Medical Curriculum Committee at Brown Medical School approved a vision for curriculum transformation that would create an integrated, patientcentered curriculum. In this article, I describe the historical evolution of curricula in American medical schools, the definition of integration, the rationale for integrated curricula and the evidence supporting it, concerns about potential negative consequences, and how the Brown curriculum may develop.

Throughout the nineteenth century, many American medical schools relied primarily on an apprenticeship model of education.1 Yet even in these schools, students undertook a course of study in the basic medical sciences during the first two preclinical years that consisted of anatomy (including histology and embryology), physiology (including biochemistry), pharmacology, pathology, and bacteriology.2 As the twentieth century progressed, new areas of knowledge were added, such as immunology, virology, and genetics, but stayed within the discipline-oriented structure.

Case Western Reserve School of Medicine pioneered an organ-system based structure to its curriculum in the late 1950s.3 Most U.S. medical schools utilize an organ-system structure in the second year of the medical school curriculum, but maintain a disciplineoriented structure in the first year of medical school, though there are many variations on the theme.

The Liaison Committee on Medical Education (LCME), the accrediting body for medical schools, still refers to the traditional disciplines in its standards when specifying what the content of medical school curricula should contain. However, the LCME has also been stressing the idea of a “coherent and coordinated curriculum” in which content is integrated within and across the academic periods of study (horizontal and vertical integration).4

DEFINITIONS OF INTEGRATION

Harden offered a very useful construct for viewing integration as steps in a ladder.5 Hardens ladder of integration has 11 steps, each reflecting a greater effort at integration. (Figure 1)

At the lowest rung, labeled “isolation,” each course is taught in isolation with the instructors of each course largely unaware of the content of the other courses. No attempt is made to modify what is taught based on what is being taught in the other courses.

At the next rung, teachers are made aware of what is being taught in other courses. Then come efforts to make connections between courses, followed by incorporation of common themes within separate courses.

The fifth rung in Hardens ladder is called “temporal coordination,” in which the instruction in separate courses is deliberately lined up with one another. For example, lectures in the pathology of lung disease occur in the same week as lectures in the pharmacology of asthma. Many medical schools have reached this level of integration, which might better be referred to as coordination, or, as some have uncharitably called them, “stapled-together courses.”

The higher rungs on the integtation ladder are much less common in medical education and are the ones that Brown Medical School aspires to reach. The sixth rung -sharing-involves joint planning and teaching in a deliberate way. A good example of this actually occurred already within the Brown medical curriculum. The human reproduction, growth, and development section of the former Integrated Medical Sciences course brought together teachers from pediatrics (Robert Schwartz), pathology (Donald Singer), and obstetrics and gynecology (John Evrard) during the 1970s. Dr. Schwartz had previously been on the faculty at case Western Reserve, so understood their model of integration. The faculty met nearly every weekend throughout the year to plan and refine the course. They planned the lectures together and attended each other’s lectures.

At even higher rungs, the proportion of student time spent in specific subjects or disciplines recedes as the amount of time in tasks that involve an integrated approach to learning increases. At the highest level, the boundaries between disciplines disappear and the students focus entirely on a new construct of understanding that transcends the disciplines.

RATIONALE FOR INTEGRATION

Dividing medicine into disciplines is an artificial construct. The real world of medical practice is transdisciplinary in large part. Physicians begin their interactions with patients in an open-ended way, even if they are specialists. The internist must consider a surgical or obstetrical or psychiatric cause of abdominal pain when first encountering a patient with that complaint.

Dividing the basic sciences into disciplines is also an artificial scheme that serves a specific purpose, namely, scientific investigation. Medical research is largely a reductionistic enterprise, delving more deeply into ever more focused areas of research. This disciplinary approach has been very successful in advancing scientific knowledge.

I was extremely pleased with the quality of the material, lectures and
discussions. The format made me feel like I had a personal relationship
with the instructors, even though this is distance learning.
–William Biermann, MD
Vice President, Blue Bell, PA

InterAct courses come in many shapes and sizes.

Some InterAct courses include video on CD, some come with an audio track with PowerPoint presentations, and others are completely Web-based text courses. No matter what the format, InterAct courses can be taken on virtually any home or office computer.

Full InterAct courses include online sessions with faculty. These sessions are 3 to 6 weeks in length, but you don’t ever have to be online at a particular time of day. The discussions and case studies that take place during the scheduled online sessions are required for graduate degree or board certification credit.

InterAct Express courses do not include a scheduled online session. These are complete, self-study courses that you take at your own pace as your schedule permits.

Essentials of Health Law

** This course will give you an understanding of laws pertaining to health care organizations.

** You’ll also focus on specific areas, including:

- HIPAA and patient rights

- Stark legislation, antitrust traps, employment contracts

- Peer review, disruptive practitioners, practitioner health

** Plus current legal trends and rulings and how they apply to your organization.

Faculty: Susan Lapenta, JD * Henry Casale, JD

Full Interact       Express Version
Course              (self study)

CME                 14                  8
Graduate Credits    14 Core             –
Online Session      Yes (3 weeks)*      No
Technology          Video on CD         Video on CD
Price               $625 members        $325 members
$700 non-members    $400 non-members

Financial Decision Making

** The ability to apply financial principles and concepts to decision making is critical for the physician executive, but is often a mystifying blend of mechanical calculation and confusing theories.

** This course provides the knowledge and skills to turn the mysteries into tools you can use to shape your organization’s strategic future.

Sudden cardiac arrest (SCA) can happen to anyone at any time–without warning. And school-aged children are not immune. An estimated 5,000-7,000 children die from SCA each year. (1) Some of them on school grounds.

For the greatest chance of survival from the most common cause of SCA, a shock from a defibrillator must be delivered within the first few minutes of collapse. (2) That’s why America’s largest school districts, including Chicago, New York City and Los Angeles have chosen Philips HeartStart Defibrillators to protect their schools.

Specifically designed for the minimally trained responder, HeartStart Defibrillators provide clear, easy-to-follow voice instructions and a simple user interface to guide the responder through an emergency. In fact, with minimal instruction, 6th-grade students were able to deliver a shock in a mock SCA event in just 90 seconds–only 30 seconds longer than it took emergency medical personnel to administer a shock. (3)

HeartStart Defibrillators are safe. Based on industry-leading technology, HeartStart Defibrillators determine whether the patient’s heart requires a shock, which is delivered only if one is needed. They are also safe to use on infants and young children. Dependable and built to last, HeartStart Defibrillators perform comprehensive daily, weekly and monthly self-tests to help ensure readiness. A visible status indicator shows at a glance that the device has passed its last self-test and is ready for use.

Most everything needed for a successful program

Philips provides site assessments, program management, medical direction, training and a wide range of financing and funding options.

Legislation for early defibrillation programs in schools

Lawmakers are also seeing the importance of school defibrillation programs. A New York law requires defibrillators to be in school facilities and at athletic events, and requires certain schools to have defibrillators capable of providing therapy for children under eight years of age and/or 55 pounds. Other states have legislation, both passed and pending, as well.

In 2000, Congress enacted the Cardiac Arrest Survival Act, extending Good Samaritan laws to protect laypersons from liability associated with good faith use of public defibrillators. Today, all 50 states have passed Good Samaritan legislation.

MEXICO CITY (Reuters)—Faced with a growing number of medical students and few training hospitals, a Mexican university is turning to robotic patients to better train future doctors.

On Monday, Mexico City’s UNAM University opened the world’s largest “robotic hospital” where medical students practice on everything from delivering a baby from a robotic dummy to injecting the arm of a plastic toddler.

The robots are dummies complete with mechanical organs, synthetic blood and mechanical breathing systems.

“The country’s rapid increase of medical students has not kept up with the number of medical facilities,” said Joaquin Lopez Barcena, an associate dean at the university’s medical school. “This a very a good learning opportunity for our students.”

The $1.3 million facility has 24 robotic patients and a computer software program that can simulate illnesses ranging from diabetes to a heart attack.

For Paola Mendoza Cortez, a first-year medical student, the robotic patients offer peace of mind.

“I would feel nervous if this was (a) real patient,” said Mendoza after drawing blood from a plastic arm. “With this (dummy patient) I can practice many times.”

With close to 15,000 enrolled students, UNAM has one of the largest medical school in Latin America. There are about 70,000 medical students enrolled in Mexico, according to the Mexican association of medical schools.

“There are medical schools sprouting out everywhere in this country,” said Martha Hijar, a medical researcher of the Mexican Institute of Public Health. “This is a very well paid major that offers status and that is why it is attracting so many into the field.”

Former Surgeon General Dr. David Satcher is the third recipient of the Association of American Medical Colleges’ Herbert W. Nickers, M.D. award. Satcher was honored at the association’s 113th Annual Meeting held last month in San Francisco. Satcher delivered an address on targeting health care disparities by increasing the diversity of medical school applicants at the meeting.

The Herbert W. Nickens, M.D. Award, named for the AAMC’s former vice president of the Division of Community and Minority Programs, is presented to an individual who has made outstanding contributions to promote justice in medical education and health care.

As Surgeon General from 1998 to 2002 and assistant secretary for health, the second person in history to hold both positions simultaneously, Satcher led the federal government’s effort to eliminate racial and ethnic disparities in health care. This initiative was incorporated into one of two major goals of “Healthy People 2010,” the nation’s public health agenda for the next several years.

Satcher is currently director of the National Center for Primary Care at the Morehouse School of Medicine, where he once served as professor and chairman of community medicine and family practice, over two decades ago.

Last year, the Nickens Award was presented to former University of Michigan President Lee Bollinger for his commitment to promoting diversity in higher education. The first recipient of the Nickens Award was Dr. Donald Wilson, dean of the University of Maryland School of Medicine, and founding member of the Association of Academic Minority Physicians.

The Association of American Medical Colleges represents the 125 accredited U.S. medical schools; the 16 accredited Canadian medical schools; some 400 major teaching hospitals, including Veterans Administration medical centers; more than 105,000 faculty in 98 academic and scientific societies; and the nation’s 66,000 medical students and 97,000 residents.

Catholic Schools: Private and Social Effects

Kluwer Academic Publishers, 2000, $100; 160 pages

By William Sander

The Education Gap: Vouchers and Urban Schools

Brookings Institution, 2002, $28.95; 275 pages

By William G. Howell and Paul Peterson, with Patrick J. Wolf and David E. Campbell

The advantage of reading The Education Gap and Catholic Schools together is in being able to appreciate their use of diverging research strategies. At the heart of The Education Gap is a large-scale study of privately funded school-voucher systems in three cities, New York, Washington, D.C., and Dayton, Ohio. The authors, Paul Peterson [editor-in-chief] of Education Next] and William Howell, mounted a randomized field trial like those used in medicine in order to rest the effects on achievement of being given a voucher to attend private school, Catholic Schools, by contrast, uses a nonexperimental approach in studying the influence of Catholic schools. The strengths of the experimental approach compensate for the weaknesses of the nonexperimenral approach and vice versa. When both types of studies yield similar conclusions, the results inspire greater confidence.

In The Education Gap, Howell and Peterson call randomized field trials the “gold standard” of social-science research. Randomized trials, built on the model of medical experiments, allow researchers to estimate the effects of a policy change by randomly sorting individuals into two comparable groups–in the case of school vouchers, a test group that receives vouchers and a control group that doesn’t. The random allocation ensures that there are no systematic differences–such as income, achievement levels, or parental involvement–between the two groups that might influence the results. Despite their advantages, randomized trials have weaknesses, the most basic being that they do not tell the researcher whether the results may be generalized to other situations, to nonvolunteers, or how the treatment variable will interact with other policy-relevant variables.

Randomized field trials are so expensive that they often must be limited to only a subset of the population of interest. For example, the study might include only a few locations and only a few grades. Even if the outcomes of the treatment and control groups differ significantly, we cannot be sure that the results will generalize to other locations and to other grades. If the experiment was limited to a single income group, we cannot know if the treatment would work equally well for other income groups. Despite these limitations, however, randomized field trials are an extremely useful type of evaluation, and they have an exceptional level of internal validity. We generally can be more confident in conclusions reached by randomized field trials than those produced by nonexperimental research as long as we do not generalize beyond the subgroups studied.

Most social-science research cannot use randomized field trials because of their expense and because it is rarely feasible to assign a sample population to treatment and control groups. Social-science researchers therefore typically observe relationships in nonexperimental settings and attempt to adjust statistically for all the relevant variables, For example, if we are interested in whether private school students and public school students have different outcomes, we try to obtain good measures for all other variables that influence the outcomes and then use regression analysis to discover whether private school students did better than the public school students. In Catholic Schools: Private and Social Effects, William Sander uses this method to study the effects of attending a Catholic school on various academic and nonacademic outcomes.

Nonexperimental research in education has two important methodological problems to overcome; omitted variables and selection bias. Selection bias is a special case of the omitted variable problem. Assume for a moment that two families live next door to each other, The parents have the same occupations, educations, and incomes, and the children have similar abilities. One family pays private school tuition, while the other enrolls its children in public schools. If we observe that the children in the private school learn more, can we conclude that private schools are better? No, because the families obviously have different values and goals. It is likely that the parents paying tuition have other characteristics that encourage their children to value education highly and to work hard in school. Statistical comparisons of public and private school outcomes must find a way to account for these unobserved, but very important, characteristics.

Randomized field trials essentially eliminate the problem of selection bias. At the same time, nonexperimental research can use large sample sizes to test the effects of Catholic schools in a wide variety of situations and to test for interactions between attending a private school and such variables as race, class, religion, and ability level. That these diverging research strategies have common findings lends them serious credibility. The most important common finding was that attending a private school significantly improves the education outcomes of African-American children in the inner cities but not of other students.

A New York State coalition of parents, educators, medical professionals, and religious leaders successfully passed a statewide resolution encouraging

a daily vegan entree option in school lunches; replacement of unhealthy a la carte and vending items with more nutritious choices; farm-to-school programs emphasizing organic choices when possible; nutrition education that includes information on healthy multicultural and vegetarian and vegan eating patterns; and a request that the Office of General Services recommend that the USDA make a greater number of healthful commodity foods available for use in schools.

East Haven Public Schools in East Haven, Conn., came up with a way to prepare students for employment in the nursing field after graduation.

The certified nurse assistant (CAN) course, which led to the school district being selected as this year’s Civic Star Award recipient for Connecticut, was initiated by David Shapiro, head of East Haven High School’s Technical Education Department. The idea was enthusiastically supported by Superintendent Martin DeFelice.

In September 1996, a registered nurse, Nancy Tipping, was hired to spearhead the program. The initiative is a collaboration among East Haven High, Hospital of St. Raphael and Laurel Woods nursing home.

The yearlong course is open to seniors only and includes classroom and clinical instruction. Students who complete the course successfully and pass the state certification test become certified nurse assistants.

Students work independently and as part of a team in caring for patients during the course. The nursing home provides a conference room for student-teacher meetings and for students to store their belongings and eat. The nursing home’s staff development director and the head certified nurse assistant are routinely available to course instructor Tipping so that student care-giving time is well-spent.

At the hospital, the director of staff development works with the school in assigning an appropriate unit for clinical work and sees that course instructor Tipping is given temporary access to the computerized supply system so that student time is not wasted waiting for items.

The head nurse and assistant head nurse are available before students’ clinical experience to review procedures, student needs and how they might help foster learning. The head nurse is available throughout the day to help in choosing patients for the students to visit and for facilitating experiences for student participation and observation.

When the class included a hearing-impaired student, the head nurse and assistant head nurse made sure staff members knew how to communicate with the student and were aware of her special blood pressure apparatus.

The hospital and Laurel Woods nursing home see their involvement with East Haven High School as evidence of their commitment to the community, which is a requirement for the facilities’ accreditation. Both have hired students after they’ve been certified, and so the program has helped them meet their need for employees. The hospital and nursing home staffs provide feedback on the strengths and weaknesses of students so that the program can be revised and continually improved.

In addition to joining the staffs of the participating facilities, students have gone on to work in home-care agencies, assisted-living facilities, doctor’s offices, other nursing homes and acute-care hospitals. Students who enter the military are given preference for medical training because they have established a medical background. Many students receive job offers the day they pass their certification test, according to Tipping.

School officials say they believe the program has helped some students who have previously experienced little academic success to stay in school so that they’ll be able to participate in the program.

Often, the program has helped students find their niche and increase their self-esteem as they do the work and learning necessary and demonstrate the skills and knowledge required to earn their certification.

Wayne County Public Schools in North Carolina was named the National Civic Star Award winner for 2005 for a school-based program to improve adolescent health care.

Since it was established in 1997, the Wayne Initiative for School Health (WISH) has improved health-care accessibility in the rural, economically depressed county by setting up medical centers in four county middle schools.

With grants from such organizations as the Duke Endowment and the Robert Wood Johnson Foundation, local and federal funding and local in-kind contributions, WISH school-based health centers are devoting attention daily to well-child care, acute and chronic health problems and psychological issues.

The idea for WISH began taking shape in 1996 when the local hospital chief executive officer and a local pediatrician, with a vision for school-based health care, established a planning team consisting of community group leaders. State statistics had shown that Wayne County ranked ninth out of 100 counties in North Carolina with the largest number of uninsured children. While children from birth to age 6 received necessary medical care on a regular basis, according to state data, the early adolescent group received little to no health-care services.

With that information in hand, the planning team aimed to improve the physical and mental well-being of middle school students by increasing access to comprehensive health care in certain communities. Areas to be targeted would be those with high levels of ethnic minorities, poverty and uninsured children and where access to health care was hindered. The four schools selected to house centers were strategically located within the county.

Parental surveys helped determine adolescent health priorities. The top three needs were deemed to be basic health care, teen pregnancy prevention and mental health issues.

Eighty-two percent of respondents said it was difficult to obtain health care for their families because of the high cost of medical services and insurance, other financial issues, lengthy waiting periods to receive services and the inability to leave work to get health care for their children. Many said they had no regular office for obtaining medical services.

Organizations represented on the planning team included Wayne County Public Schools, the Wayne County Health Department, Goldsboro Pediatrics, Wayne Memorial Hospital, Communities In Schools, Wayne Community College, Wayne County Department of Social Services and Wayne County Mental Health. They established WISH as a nonprofit 501c3 nonprofit organization.

Leaders of Wayne County Public Schools were among the strongest advocates of school-based health centers. The centers were designed and built by the school superintendent and a dedicated staff. Each center is about 1,000 square feet and consists of two exam rooms, a laboratory, reception area, medical office space, a restroom and a group counseling room. Maintenance, custodial services, electricity and water are provided by the school district.

A school board member is on the WISH board of directors, and an additional central office staff member also meets with the board.

The community partner organizations provide most of the staffing for the centers, including a registered nurse who is the clinical director, health educators, nutritionists and mental health counselors. The county government has provided significant annual financial support for the program.

Successes documented at the centers include:

* A 75 percent decrease in teen pregnancies.

* Improved performance on required standardized tests.

* A 4 percent improvement in school attendance.

* A dramatic decrease in emergency room visits by adolescents.

* Enrollment in the WISH centers of 85 percent of the student body at each school.