Wiring The New Docs

At UCLA Medical Center last month, three medical students stopped by to say hello to a patient about to undergo routine gallbladder surgery. They were making small talk when the 55-year-old man, who was connected to a heart monitor and had IV lines in place, suddenly stopped breathing. The students were the only medical personnel present, and their collective stress level soared as they scrambled to figure out what was wrong. They administered a sedative and ran a tube down the man's throat to aid his breathing. As the situation stabilized, the testy surgeon, unaware of the emergency, called the room looking for her patient. "I have clinic in the afternoon," she barked at the students over the intercom. "I can't be futzing around here all day." Just then, the crisis deepened as the patient's heartbeat raced out of control and his blood pressure plunged. Later, the students would discover that he had suffered an allergic reaction to the sedative they had given him and gone into anaphylactic shock. But they didn't know that at the time. All they knew was that the patient was dying and they had only minutes to save him. They gave him fluids and epinephrine to increase his blood pressure and shocked him twice with a defibrillator to restore his normal heart rhythm. When the surgeon called again, fourth-year student Janet Huamani took an extraordinary step. "I'm canceling your case," she said, and told the doctor the patient was going to the ICU, not the OR.

In a small room next door, associate clinical professor Dr. Rima Matevosian, who had watched on a video monitor, nodded in approval. "That's the appropriate response," she said. Then she turned to the technician seated beside her. "OK," she said, "complete recovery." The technician tapped away at her keyboard, the same one she used to generate the near catastrophe, and in a matter of seconds the traumatized patient's vital signs were all back to normal. Stan (short for "standard man"), the life-size, computer-controlled Human Patient Simulator, had survived yet another close encounter with simulated death. And the students, whose stress was clearly not simulated, had sweated through yet another nerve-racking lesson about the inherently unpredictable nature of medicine and patient care. As she prepared to join the students for a videotape review of their performance, Matevosian summed up her opinion of this dramatic approach to medical education: "Simulation saves lives."

Just as technology is transforming the practice of medicine and the experiences of patients, it is also changing the way tomorrow's doctors are being trained. Today's medical students have an unprecedented arsenal at their disposal--from simulators that breathe and respond to treatment like real patients (and sometimes even die), to pocket-size personal digital assistants (PDAs) that can hold entire medical texts, to CD-ROMs that enable students to listen to the sound of nearly every known heart condition, and more. Medical schools around the country are turning to technology to help their students learn even as they recognize the need to emphasize the human touch. At Tufts University, the entire curriculum for the first two years has been transformed into the Tufts Health Sciences Database, a massive, integrated online system. The University of Louisville School of Medicine has created a state-of-the-art patient-simulation center.

At UCLA's David Geffen School of Medicine, where PDAs are required for students but microscopes are optional, the students, faculty and administrator are surfing this technowave with gusto. Since 1996, when the school first required medical students to have computers, UCLA has spent millions turning itself into the very model of a 21st-century medical school. "Every patient is a little different," says Zane Amenhotep, who just completed his third year, "so there's always going to be a limitation to technology. You can't use it as the only tool, but it's an excellent foundation."

In practice, the technology serves two basic purposes. The simulators enable students to gain hands-on clinical experience sooner and without any risk to patients, while the PDAs, the CD-ROMs and the Web-based curriculum (each course at UCLA has its own Web site) help them manage and absorb an enormous and ever-expanding amount of information. At UCLA and other leading schools, the rise of technology has accompanied fundamental curriculum reforms that emphasize small-group, case-based learning right from the start. As a result of these dual trends, today's medical students learn much earlier to act like doctors, to think like doctors and to behave like doctors. The old didactic approach to medical training--in which students spent their first two years attending lectures and memorizing facts before being dumped clueless on the wards in their third year--is as dead as the cadavers they cut up in gross anatomy (sidebar).

When Randolph Steadman was a medical student at the University of Florida in the 1970s, the residents got to have all the fun. "If somebody's heart stopped, I'd get elbowed to the back of the room," recalls Steadman, associate professor of clinical anesthesiology and director of UCLA's Simulation Center. Now, with Stan, even first-year students get to experience the unique horror of having a patient go south with no warning. "It's a controllable bedside," he says. "We can incorporate more significant events much earlier on in the training." Stan solves another old problem in medical education. When third-year medical students are seeing patients with him, Steadman says, they tend not to speak up unless they know exactly what to say. "They're only going to chime in when they can shine," he explains. "So it's very hard for me as the teacher to know where the gaps are in their knowledge. The simulator uncovers all of that. I can see their gaps."

The simulations, based on actual cases, teach the students how to think their way through medical emergencies. The sessions with Stan also teach reverence for detail, as well as the need for teamwork and clear communication. Perhaps most important, the simulations get students accustomed to actually doing stuff to patients. The first time Noah Rodriguez had to run a tube down the throat of an actual human being, he was grateful for his sometimes bumpy experiences with Stan. "You've done it before, so you go in knowing that it's not going to be as easy as those guys on TV might make it look," says Rodriguez, who is starting his fourth year.

While the simulations provide an opportunity to practice acute care, PDAs and online databases give instant access to critical information. Everybody's jacked in all the time, looking up some key detail or downloading some important new paper. "Medicine is information overload," says Rodriguez, and PDAs are one way to deal with that. The typical student's PDA contains a medical dictionary, a pharmaceutical guide, a medical calculator with equations for things like blood-gas analysis, and the very popular "Griffith's 5-Minute Clinical Consult," which is packed with information about symptoms, diagnoses and treatment options. And there's always room for more. When Rodriguez rotated through psychiatry, he downloaded the entire fourth edition of the Diagnostic and Statistic Manual of Mental Disorders into his PDA. "I truly do believe that the computer is the physician's black bag of the future, along with the stethoscope, if it's used the right way," says senior associate dean Dr. Neil Parker. "You can't possibly know and remember everything that you need to know. You can't keep up on the literature, you can't keep up with the clinical guidelines."

And how does this reliance on microprocessors affect patients? "We should be able to eliminate mistakes due to lack of knowledge," says Luann Wilkerson, senior associate dean for medical education. That's not the only source of mistakes, obviously. But, says Wilkerson, no one will be able to say he made a mistake because he didn't have access to the right information.

At UCLA, technology also creates a thriving online community where students and faculty engage in a never-ending discussion of medical topics. There are formal settings, like the Web-based course called Clinical Application of Basic Sciences, in which small teams of students spend weeks on a single case, posting their research online as they work up a diagnosis and treatment plan. "You don't have to get bored," says Sammy Eghbalieh, who just completed his first year. "You're not sitting in a classroom for three or four hours." And there are informal settings, since each class has a Web site, as do many of the students and faculty members.

It's clear that medical education is only going to get more gizmo-centric. UCLA has just opened a robotic-surgery suite as part of a new program called the Center for Advanced Surgical and Interventional Technology. And its $800 million, 525-bed paperless "all digital" hospital is scheduled to open in 2005. Is it too much of what might not be such a good thing? "It would be easy to get lost in the vast amounts of information," says Amenhotep. "You have to be careful not tolet that happen. You still have to be a good clinician."

Dr. Mike McCoy, chief information officer of the UCLA Medical Center, who is directing the development of the new digital hospital, couldn't be more of a tech guy. But McCoy, who flew fighter jets during the war in Vietnam, knows the real secret to getting the most out of technology. "Good pilots, even though there's wonderful navigation systems now and all kinds of satellite aids and so forth, they always know where they are," he says. When McCoy was heading back from North Vietnam to South Vietnam after a mission, he could never quite bring himself to trust his plane's computer. "I always looked at my humble magnetic compass to make sure that it also said south," he recalls, "because the consequences of going north from Hanoi were not good. And we teach that to the students. They have to look at the patient. If the oxygenation number looks good but the patient is blue, something's wrong." Cutting-edge technology can never replace a doctor's best judgment.