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Mesothelioma: A Killer
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Harvard Program Stresses Patient Care
By JUSTIN POPE
AP Education Writer
CAMBRIDGE , Mass. (AP) -- At Harvard Medical School, as elsewhere, most students will see a dozen births or more during a three-week obstetrics rotation, but they rarely will meet a mother before she arrives at the hospital, or see her again once she leaves. On other rotations, they may see acutely ill cancer patients, but they may not be there to break the news, or follow them and their illnesses over a course of chemotherapy.
Eight third-year Harvard students are part of an experimental program that hopes to address those shortcomings by casting aside the traditional hospital rotation system. Rather than moving from specialty to specialty every few weeks for intensive blocks of training, they are following individual patients, wherever their conditions take them in the health care system.
Some patients are pregnant, others ill - either already diagnosed with complicated medical problems or picked up in the emergency room before anyone knows what is wrong.
If the patients have specialist appointments, the students accompany them, even sitting with them in the waiting room. If they need surgery, students observe and assist. In some cases, they visit patients at home. And if patients die, as has already happened in the early months of the program, students will be there for that, too. The hope is that these relationships will both help the students become more empathetic physicians, and make the science they are supposed to be learning stick in their minds.
"We remember experiences because they are meaningful to us," Harvard medical student Carolyn Casey said.
The experiment is one of several around the country that concern clinical training, though Harvard's is "unique in scope," said Dr. Michael Whitcomb, senior vice president for medical education at the Association of American Medical Colleges.
The efforts are emblematic of a growing dissatisfaction among some medical educators with the clinical training that students receive in their third and fourth years of medical school, after two years in the classroom.
That discontent stems from significant changes at the teaching hospitals where clinical training takes place. Patients once spent weeks in teaching hospitals, and students could follow them from diagnosis through treatment. Now teaching hospitals, like other medical centers, shuffle patients quickly in and out, and students get little more than a snapshot.
Teachers involved in the Harvard program say typical medical students aren't getting the same human contact that instructors remember from their training days. Nor are students necessarily getting interdisciplinary views of illnesses, which don't always fit neatly into categories.
Perhaps most importantly, the teachers worry students aren't practicing the skills that, for all of the changes in medicine, are still supposed to be the focus of the third year: taking patient histories and thinking through a diagnosis.
In the past "you had students involved in really core thinking that was going on to diagnose a patient, and you were with a patient long enough to see it actually happen," said Dr. Barbara Ogur, one of two co-directors of the Harvard program. "That was being totally lost." The focus in teaching hospitals now is on stabilizing patients; often a diagnosis has already been made, or the patient is discharged before it is completed, she said.
Still, the prevailing rotation system has lasted for decades because it has its virtues: it exposes students to a range of cases, is relatively easy to organize, and offers hospitals a pool of free labor. In 2000, an Association of American Medical Colleges survey found that medical schools had responded to the explosion of new drugs, technologies and treatments with a substantial retooling of the classroom portions of their curricula, Whitcomb said. But the third and fourth years of medical school had been largely untouched.
Reform has been "remarkable for its slowness," said Dr. Kenneth Ludmerer, a historian of medical education at Washington University in St. Louis. Several similar attempts at changing clinical rotations during the 1950s failed, he said. Even as health care has become increasingly outpatient, "it's been so convenient for hospitals to keep teaching in the hospital," he said.
Dr. David Hirsh, Ogur's co-director, admits some colleagues have been skeptical about the new program, and even he isn't sure it could work on a broader basis.
"My biggest concern is scaling up," he said. "It may be the best thing since peanut butter. But the question is, is that because we're putting a tremendous amount of resources into only eight people?" The logistics have been tough, he said, as has been lining up the extra teaching the students need to cover material they might not otherwise see. And even if Harvard could make the system work for all 170 students in a class, that's no guarantee poorer or larger programs could do so.
Hirsh says the key to success is picking patients who will expose the students to the widest range of experiences.
A typical example is Catalino Rodriguez, who on a recent afternoon visited student Joanna Epstein at the Windsor Street Health Center in Cambridge, an outpatient clinic. Rodriguez has a variety of complicated and considerably interconnected health issues: a leg injury from a workplace accident, heart problems, and most recently a dangerous infection that hospitalized him for five weeks. He also is in recovery from substance abuse.
Epstein first met Rodriguez during his hospital stay; he went to the Windsor Street Center with girlfriend and caretaker Patti Miller, who worried that a recent, small spike in his temperature could signal a recurrence of the infection. Epstein and Ogur, who joined the appointment later, concluded that it wasn't an immediate threat but told Rodriguez to watch his temperature carefully.
"When you're at a hospital, seeing someone you know, a friendly face, it makes you feel a little more comfortable," Rodriguez said of Epstein. "She can speak up for you."
Miller said Epstein also helped her deal with the stress of Rodriguez's hospital stay. "She's younger, she's more our age," she said. "I think it's easier for us to talk to her."
Epstein says the relationship has paid off for her, too.
"He's actually my teacher," Epstein says. "I tell him, he's a Harvard professor at this point. He can add that to his resume."
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On the Net:
Harvard Medical School : http://www.hms.harvard.edu
© 2004 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
Virus not linked to type of lung cancer
Last Updated: 2004-09-24 15:49:13 -0400 (Reuters Health)
NEW YORK (Reuters Health) - Infection with simian virus 40 (SV40) plays little or no role in the development of mesothelioma, a cancer affecting the lining of the lungs that has been linked to asbestos exposure, according to a report in The Lancet.
In the 1950s and 1960s, several hundred thousand military recruits in the US received a vaccine contaminated with SV40. Since then, concerns have been raised that SV40 may cause cancer after researchers noticed the presence of its DNA in various tumor specimens.
However, the new results indicate that the SV40 DNA seen in these specimens may have simply resulted from contamination in the lab -- the virus was not actually present in the tumor before it was removed from the patient.
The current findings are just the latest in a series of reports that have failed to show a link between SV40 and various cancers, such as mesothelioma, lymphoma, and brain tumors.
In the study, Dr. Marc Ladanyi and colleagues, from Memorial Sloan-Kettering Cancer Center in New York, looked for SV40 DNA in 71 mesothelioma samples.
The authors found no evidence of genuine SV40 DNA in the tumor specimens. They did, however, find SV40 DNA that came from circular molecules called plasmids, not from the virus itself. The researchers suggest that these plasmids were probably introduced as contaminants in the lab.
"Because SV40 appears unlikely to have a major role, if any, in human mesotheliomas, (doctors) should continue to consider asbestos exposure as the most likely and most thoroughly established (cause) in individuals with this cancer," the researchers conclude.
SOURCE: The Lancet, September 25, 2004.
Copyright © 2004 Reuters Limited. All rights reserved. Republication or redistribution of Reuters content, including by framing or similar means, is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Reuters and the Reuters sphere logo are registered trademarks and trademarks of the Reuters group of companies around the world.
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