It’s a dilemma.

Try to teach a medical student everything there is to know about medicine, and that student will probably never graduate for the flood of new and vitally important medical information being published each day.

Teach just the basics, as traditionally they have been taught in years past, and that student graduates woefully underprepared to meet the medical challenges faced by today’s physicians, not to mention the more medically informed patients they encounter.

The solution: Teach medical students to be life-long learners and give them the tools and the skills they need to research patient care cases and solve problems.

Curtis Wise, Ph.D., calls it an explosion of information, this geometrically expanding cache of biomedical research, treatment protocols and advanced technology. It’s more than any one human being can contain. But Wise, an MUSC professor of physiology and the university’s pioneer in the use of computer-based instruction in biomedical education, has used a convergence of expanding scientific information and computer technology to teach medical students how to solve problems presented by patients and to use the computer to search for information and get answers quickly.

In the process, the MUSC College of Medicine is producing graduates equipped to learn their medical practice as long as they practice medicine.

“Medical students have been using computer-based instruction for 10 years now,” Wise said. “It’s medical informatics, the whole science of computers as tools in medicine. We teach them to use the Internet to access our library and its databases to get information faster.”

Wise also has used Internet technology to present information to students who normally would attend a lecture, go to the library, or compete with each other to view a video tape or an X-ray film. Instead, they can get up in the morning, boot their computers and log-on to a class web site with their identification code and password. There they can receive the day’s instruction, a class syllabus, a patient case study to solve and a list of linked Internet sites to evaluate for information, perhaps X-rays to scrutinize, and images of specimen slides to examine.

In the afternoon, they use the information they gathered to discuss their case and present solutions.

“I think we’re more used to textbooks, but we’re learning to use the Internet to research our cases,” said first-year parallel curriculum medical student Barry Jenkins. Jenkins, who is among 18 freshman medical students at MUSC participating in the parallel curriculum, said that while he relies heavily on e-mail to keep in touch with other students in his College of Medicine class, he anticipates spending more time searching journals in the MUSC library databanks as he progresses.

Jenkins sees the Internet technology available at MUSC as a way for his class to “leave our legacy” to the classes that come after his. “We all have differing strengths and interests and this is a high-tech way of sharing our notes and the results of our problem-based study with each other and with the classes after ours.” He said that scanning notes and diagrams into the Internet web site makes their work available to anyone who needs it.

“Barry will be learning basic sciences and clinical medicine while in an intensive community experience May 11 through June 19,” said parallel curriculum co-director Imogene Smith, Ed.D. “The Internet will be his link to MUSC.”

Working with volunteer preceptor Dr. William D. Brearley of Lexington, Jenkins will be among the first parallel curriculum students to carry portable computers to selected sites throughout South Carolina for the community experience. With the computer and a phone line connection to the Internet, Jenkins will have access to the MUSC library and its resources and so will his preceptor.

“We hope the computers will serve as a model for the physicians our students will be working with,” Smith said. “Many doctors have Internet connections and use them, but many don’t.” She said that MUSC encourages South Carolina doctors to serve as volunteer preceptors and in return offers them the Internet connection to MUSC resources, on-site help with the setup, and a clinical affiliation with the MUSC Medical Center.

“This collaboration and team participation that students are learning now will carry over into the real world of patient care,” Smith said. “With the knowledge in patient care expanding and changing so rapidly, they need to work together.” She said Internet technology is fast becoming the way to make that happen.

Students, computers bring value to practice

Advances in medical technology and changes in reimbursement have moved more and more patient care out of the hospital and into community physician practices. Even surgeries that once required an early morning pre-op and an additional night’s stay for recovery are now being performed routinely on an outpatient basis with improved outcomes and lower costs.

“We have to train students where most health care is being provided, in the community,” said Department of Family Medicine associate professor Alec Chessman, M.D.

So third-year medical students in the Family Medicine Junior Core Clerkship are distributed among the seven S.C. AHEC (Area Health Education Consortium) family medicine residency training program’s practices throughout the state or to rural practices to learn how to provide community-based primary care.

As they travel to another part of the state, students remain connected by computer.

Each of the AHEC sites are connected to MUSC by the Internet, Chessman said, and those who go to rural areas will soon begin to carry portable computers with them. He explained that for the last three years each student has been required to do MEDLINE searches. Each student identifies a clinical question relating to the care of a specific patient, and then searches the MUSC library’s MEDLINE database for an answer.

MEDLINE accessed through the Internet keeps the students up-to date no matter where they are in the state.

By using computers to do such things as access MEDLINE, students can add value to a physician’s practice. “Students can be seen as a drain on the practice,” Chessman said. “They take time that could be spent with patients. In an age of cost-cutting in medicine, time is money. We have a wonderful paid and volunteer faculty around here and throughout the state, but we have to make sure that the student brings value to the practice and that the doctor knows it.”

One way is to provide a computer and an Internet connection to MUSC with each student. A quick MEDLINE search has helped medical students find information about rare conditions, when textbooks and course syllabi provided no help. MEDLINE has helped students find the solid ground of evidence, when preceptors and authors give conflicting advice. Chessman hopes that the ability to connect to MUSC information resources will catch on, that doctors will see the value of the computer to their practice and begin to use its power to access the latest and most reliable information.

The move toward a heavier reliance on technology is not without its stumbling blocks, however. Chessman cites phone connection problems encountered. And there’s the set-up problems that can keep a doctor from going on-line. Just one simple problem that remains unsolved can render a computer useless.

And then there’s the selection problem, Chessman said. “How do you know that information on the World Wide Web is reliable? Even the best of peer-reviewed journals may contain trash, and web sites are not typically peer-reviewed.” He added that essential to every medical student’s education is the acquired ability to discern which information is valid and which is not.

Part of the curriculum is getting the students to search web links relating to common topics in family medicine. “With the help of Frank Starmer, Ph.D., associate provost for information technology, and Tom Basler, Ph.D., director, Libraries and Learning Resource Centers, we are generating nests of links around common medical problems and such issues as continuous quality improvement and health promotion/disease prevention for our students to investigate and use.

“I think more and more doctors will be seeing patients who come to them saying, ‘I read this on the Internet. What do you think?’ With an Internet connection, the doctor can ask for the site location and investigate the source.”