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Vital Signs

National pharm recommendations had DMS roots

By Amos Esty

Afew years ago, in the middle of a lecture, DMS's Dr. David Nierenberg felt a sharp pain in his side. "I literally jumped at the podium," he recalls. Realizing almost immediately that he had a kidney stone, Nierenberg ended the class and drove himself to the DHMC emergency room. "The diagnosis wasn't hard," he says. "I walked in with the diagnosis." The tricky part was how to treat the problem. Which drugs would ease his pain and help him pass the stone without conflicting with allergies or other medications?

Two: The two doctors who arrived to discuss his treatment options looked familiar to Nierenberg, the senior associate dean for medical education. Both, it turned out, were DMS grads who'd taken his required fourthyear pharmacology course. "I hope they know wha t they're doing," Nierenberg recalls thinking. The incident had a happy ending medically, and it also reinforced Nierenberg's belief in the importance of teaching medical students how to be competent prescribers.

"We are graduating medical students who will turn into the doctors who will be treating us and our families," he says. "If we don't train them well, they will not take care of us well."

Strong: Nierenberg has been encouraging the nation'smedical schools to update their pharmacological curricula since he arrived at Dartmouth in 1981. The training at DMS is quite strong, he says, but many other schools still lag behind. So he was thrilled to be asked to chair a panel convened last year by the Association of American Medical Colleges (AAMC) to examine the problem. In July, the group issued its report, "Education in Safe and Effective Prescribing Practices," the 10th in a series of reports onmedical training published by the AAMC.

The panel discussed what medical students need to know by the time they graduate in order to be effective prescribers, and how best to teach them that information. The skills mentioned in the report include being familiar with the long list of drugs available today, knowing how to find up-to-date information, and communicating to patients the risks and benefits of potential treatments.

To ensure that these skills are taught, the report recommends increasing the amount of training students receive in prescribing. Now, Nierenberg says, most schools require a course in basic pharmacology in the first or second year; he'd like to see a course in the fourth year, too, similar to the one he teaches at DMS. "What I love about the fourthyear course is that it's a capstone course," he says. "It integrates everything that's happened in the first three years."

However, Nierenberg realizes there are reasons that not every medical school has followed DMS's lead. Some resist adding required courses in the fourth year; others may not have the faculty needed to teach such a course. "Where do you get the time and resources?" he asks. "That's really the problem."

Essential: Still , given the changes in medicine over the years, Nierenberg believes that the report's recommendations are essential. "There weren't too many drugs 50 years ago that could kill you fairly quickly if they weren't used properly," he says. "But now we have a lot of drugs that can do that."

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