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DMS students can click on CLIPP to learn pediatrics

All Dartmouth medical students doing a pediatric clerkship this year will get to know two-weekold Tyler when he and his mother come in for a routine outpatient visit. Since students work in 19 different community practices throughout New Hampshire and Vermont, this suggests that Tyler and his mom spend a lot of time on the road. Actually, thanks to the Computer-assisted Learning in Pediatrics Project (CLIPP), which is being developed at Dartmouth, Tyler stays home and the students meet him on the Internet.

When it's completed in June, CLIPP will include 31 different cases, including Tyler's, in an interactive learning program that covers the core curriculum for pediatric clerkships, as developed by the national Council on Medical Student Education in Pediatrics (COMSEP).

Leslie Fall (left) and Norman Berman (right) are working to bring a comprehensive clinical pediatrics experience to medical students anywhere through the Internet.
Photo: Mark Austin-Washburn

Clerkships put students in a clinical setting, where—under close guidance—they meet patients and take part in diagnosing illnesses and recommending treatments. While the clerkship represents a quantum leap from the classroom for students, it is limited by time and place. During their seven-week pediatric clerkship, DMS students are apt to see only illnesses and injuries common at that time of year in northern New England.

"There is a high likelihood of missing major clinical issues," says Leslie Fall, M.D., co-director of CLIPP and director of medical student education in the pediatrics department. Students may, for example, never encounter a patient with HIV infection or sickle-cell anemia.

Remedy: Fall—with CLIPP's other codirector, Norman Berman, M.D.—came up with an ingenious remedy. In 1993 and 1994, Berman had developed a pre-Internet program containing clinical simulations, but it was available on only one computer in the DMS library. Martin Fischer, a German physician visiting Dartmouth, was very interested in Berman's work and the possibility of using it on the Web. Upon his return to Munich, Fischer started working with a software developer to come up with an interactive program so medical students could work through cases just as they would in a clinic.

In 1999, Fischer came back to Dartmouth to demonstrate the program; Fall and Berman have taken it from there. "The software incorporates an element that challenges students to think diagnostically," Fall explains. As a case unfolds, students get a little information at a time, answer questions based on that information, and then get feedback on their answers. This simulates a clinical situation in which a student would take a patient's history, perform a physical exam, order tests, assess the information, make a diagnosis, and come up with a plan for managing the patient's condition.

"And all of this can be done in a safe environment," Fall says, where students aren't making decisions about actual patients. Rather than simply converting Berman's original cases to the new software, he and Fall sent out a call for case authors through COMSEP. "Our goal was to spread the project content nationally," Berman explains. Each of the 31 authors worked with two COMSEP mentors—a content advisor and a technology advisor—and each case was peer-reviewed. The result is a national consensus-based curriculum. "To the best of our knowledge, nothing like this has ever been done," Berman adds.

The program also provides opportunities for consultation (by clicking on an "Expert" button) and research (by clicking on "Hyperlinks"). In Tyler's case, for example, his mother is worried that he isn't gaining weight. By consulting the expert, a student discovers that newborns usually lose 5% to 10% of their birth weight but return to that weight within two weeks. Since Tyler remains below his birth weight, there may be a problem. By the time students reach the diagnosis stage, they have determined that Tyler has breathing difficulties that interfere with nursing. They then propose possible diagnoses and decide which one best fits Tyler's symptoms.

Once students complete all the cases, "they will have seen the 30 most important things," Fall says. Berman adds, however, that CLIPP is meant to supplement, not replace, actual clinical experience.

When Fall and Berman unveil CLIPP at the national COMSEP meeting in April, they will be able to present feedback from students at Dartmouth, Morehouse, Vanderbilt, and Meharry Medical Schools.

Model: They will also have a chance to talk about the project's broader implications. Not only can the CLIPP model be applied to other specialties, but it is available wherever there is Internet access. To meet Tyler and learn more about CLIPP, visit www.clippcases.org.

Catherine Tudish

If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.

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