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Medicine as art

Dr. Alan Friedman is the second of three generations of ophthalmologists in his family—all Dartmouth graduates. Pictured here in 1994 at the New York Eye and Ear Infirmary are, from the left, Alan Friedman, DC '56 and DMS '57; his son, Neil, DC '88; and his father, Joseph, DMS '28.

By Kate Villars

Are doctors losing touch, literally, with their patients? That's what one Dartmouth Medicine reader—herself a physician—asked in a recent letter to the editor, lamenting what she described as a lack of caring touch when she was recently hospitalized. "It seems the physical exam has gone out of style," she wrote, wondering what was becoming of the close doctor-patient relationships she had once known.

Dr. Alan Friedman, DMS '57, wants to ensure that this intimate and important part of caring for patients remains front and center in today's Dartmouth medical curriculum. He is deeply troubled by what he sees as a trend in the nation's medical schools away from teaching the basic skills of taking a medical history, conducting a physical exam, and communicating in ways that foster trusting doctor-patient relationships.

His convictions have motivated him to establish a $1-million endowment at Dartmouth Medical School to support its training of young physicians in what he describes as "the art of medicine."

"I don't want this to be lost," says Dr. Friedman, an ophthalmologist and an associate professor at the New York University School of Medicine. "I think every medical student should graduate with these skills, which is why I'm so passionate about this endowment. We need to expose students to what it is to truly be a doctor—not just to be a technician, not just to be a scientist, but to know how to interact with patients in a way that instills confidence and trust. I think Dartmouth Medical School is the ideal place to promulgate this, because it's small enough and has a humanistic attitude."

Kate Villars is assistant director of development communications for DMS-DH.

At DMS, much of this learning takes place in On Doctoring, a required course that spans the first two years of the four-year curriculum. "We focus on the fundamentals of doctor-patient interviewing and the physical exam, and on understanding the doctor-patient relationship and its importance—all key pieces to becoming an effective physician," says Dr. Nan Cochran, an associate professor of medicine and the course director for On Doctoring. "These are essential and teachable skills," Cochran adds.

Dr. Alan Friedman, the host of a 2008 reception for New York-area DMS alumni, is pictured here making some remarks at the gathering.

"When our graduates become residents, they're often singled out for their competence in medical interviewing and the physical exam, and for their compassion," says Dr. David Nierenberg, DMS's senior associate dean for medical education. "These clinical skills are important, because a careful history and physical exam may tell you more about your patient than a whole battery of costly tests. And, of course, technically competent care, delivered without concern and compassion, is not what our patients hope for and expect."

Alan Friedman, the second of three generations of ophthalmologists in his family, absorbed this approach to medicine from his father. "I was steeped in medicine from the time I was a toddler," he says. "Initially my father practiced in the apartment where we lived, and then on the first floor of our brownstone in Brooklyn. He was a wonderful role model—very empathic with his patients, very compassionate, an excellent physician. I was shaped by that exposure to him." As a medical student, Alan Friedman shadowed his father at Brooklyn Eye and Ear, and later he worked with his father as he began to build his own private practice in New York City in the 1960s.

A Dartmouth graduate just like his father, who was a DMS '28, Alan Friedman attended both Dartmouth College and DMS, where the lessons he had learned at home were further reinforced by DMS's legendary dean, Dr. Rolf Syvertsen, and others.

Today, DMS's On Doctoring course is taught primarily through weekly small-group sessions during which students learn and practice clinical skills, both on each other and on a cadre of standardized patients drawn from the community. In addition, students are assigned to a clinical preceptor site, where they see their first actual patients as they work one-on-one with doctors. The small groups also provide a forum to discuss and reflect on these clinical experiences.

DMS "is the ideal place to promulgate this, because it's small enough and has a humanistic attitude."

"The students love being introduced to patients in the fall of their first year, because learning to care for patients is why they came to medical school," says Cochran.

"It's nice to be introduced to these skills early, so it's a slow building-of-knowledge process," observes a first-year student about the On Doctoring course. "We all recognize these are important and powerful tools to use later on."

And a second-year student says of the course, "This is the best educational experience I've had in medical school."

Dr. Nan Cochran, course director for DMS's On Doctoring course, teaches the eye exam to, from the left, first-year Regina Duperval and second-year Matt Mackey, while second-year Jill Kaspar plays the role of the patient.

The resources required to provide faculty to facilitate 22 small groups, to hire and train 30 standardized patients, and to recruit and manage over 170 clinical preceptors at more than 40 sites, all while maintaining a consistent level of excellence, make the On Doctoring course a significant investment. The Friedman endowment will provide critically needed funds to sustain and expand this important aspect of the DMS curriculum. "We're incredibly grateful for this gift because it will enable us to really strengthen our training," says Cochran.

"Alan Friedman and I completely agree about the sacred nature of the doctor-patient relationship and the importance of building respect and trust," adds Cochran. "Because only then will our patients open up and be honest and forthcoming about the challenges in their lives, including issues that are difficult to discuss. Once there is a solid foundation of trust, we can more effectively draw on our complete knowledge base to diagnose disease and provide care that is appropriate to that individual."

Friedman and Cochran also share a bigger vision—one that extends beyond DMS. "I think every medical school has to get back to these basics," says Friedman. "I'd like to see this everywhere. If what we've started here can help turn things around, we will have accomplished our goal."

Fisher Cats champion CHaD
The Granite State's own baseball team, the New Hampshire Fisher Cats, has raised over $270,000 since 2007 in support of the Children's Hospital at Dartmouth-Hitchcock (CHaD). The team's annual Granite State Baseball Dinner has become a "must attend" for fans, featuring greats from the Red Sox and Blue Jays, as well as upand- coming Fisher Cats. Read about other "CHaD Champion" businesses at the CHaD Champions website.

DHAF enjoys strong support
Over halfway through the fiscal year (which ends June 30), more than 2,200 donors have given over $535,000 to the Dartmouth-Hitchcock Annual Fund (DHAF). This generous support provides critically important unrestricted funds to help D-H meet its commitment to providing the best possible care for each person, every time, close to home.

Kate Villars is assistant director of development communications for DMS-DH

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