redundancy among courses; changed the ob-gyn rotation to include general outpatient women's health; infused more clinical material into the first two years and more basic science material into the clinical years; and established itself as a national leader in medical education and medical education research (see page 7).

"We are teaching stuff we didn't do 10 years ago," Nierenberg says. "Medical ethics, cultural competency, increased attention on communication skills, whole new curricula on how the health-care system works, how to work in teams, how to try to improve what you are doing."

But to improve, one must first evaluate the status quo. Nierenberg's favorite tool for assessing medical education is the Dartmouth Medical Encounter Documentation System (DMEDS), launched in July 2004. He leans forward in his squeaky office chair, opens the DMEDS database, and starts reading aloud from it: "Patient was mentally disabled. Much of the history was provided by a friend/employer. Patient was 52 years old and had never seen a doctor." This is just one among thousands of entries made by students about patient encounters during their clinical rotations. "That's a really powerful statement of how hard that student had to work to find out what was going on with that patient," Nierenberg says. The data in the system is used in the aggregate to see what gaps there may be in students' experiences and to ensure consistency among numerous clerkship sites.

Some of the inspiration for DMEDS, which Nierenberg helped develop, came from his work in the late 1990s on a national committee that revised the U.S. Medical Licensing Exam. The committee converted a multiple-choice section to interactive computer-based case studies. Now, the exam presents fictional patients. Students can ask for the patients' histories, physicals, and lab-test results and then must select diagnoses and treatment plans.

Nierenberg reads another DMEDS entry: "'Patient's from Liberia and spoke a different dialect of English.' This student had to learn to rephrase questions in 'a more simple and clear way to facilitate direct communication,'" he explains. "That's an advanced communication skill. That's what we want our students to wrestle with before they go out and be a doctor."

Other medical schools have computer-

Nierenberg believes that using pens and other freebies to market pharmaceuticals prevents doctors from being "clearheaded about prescribing the drug that is most effective."

based systems that record clerkship experiences. But Dartmouth appears to be the first to track its students' acquisition of the competencies now required by residency programs; it's expected that these competencies will soon be required of medical students, too. They cover six areas: medical knowledge; clinical skills for patient care; interpersonal communication skills; professionalism; practice-based learning and improvement; and the ability to navigate a complex health-care system.

The fact that DMEDS is based on these competencies is "huge," says Patricia Carney, Ph.D., DMS's assistant dean for educational research. She helped to develop ClinEdDoc, DMEDS's predecessor, and has worked with Nierenberg for 10 years. "He has been very insightful about the evolution of medical education," she says of her colleague. "He's always looking to improve it."

Carney is also familiar with Nierenberg's willingness to speak out on issues he thinks are important. "Boy, if he really believes in something, he stands there for it," she says, in a way that suggests she's been on the receiving end of his resolve more than once.

And Nierenberg really believes that using pens and other freebies to market pharmaceuticals to physicians is wrong. The "dirty" pens he collects from students are relegated to a box on the crowded shelves of his lab. And on the top shelf sits a larger box labeled "Hall of Shame," which contains such doodads as a colorful "Ene-man" superhero advertising Fleet enemas and a stuffed, talking "stuffy nose" embroidered with "Allegra-D."

Such "crap," he says, is "getting in our way" and preventing doctors from being "clear-headed about prescribing the drug that is most effective for their patient, safest, and—all other things being taken care of—least expensive." The idea that a trinket could alter physicians' prescribing practices is pooh-poohed by some. But, Nierenberg asks, would drug companies spend billions of dollars a year on marketing if it didn't work? "It's about name recognition," he insists. "That's

what's in a pen. It alters perspective."

His favorite anecdote to illustrate this point is one that a fourthyear medical student wrote about for the clinical pharmacology course he developed. In her paper, the student described the excitement of nailing her first diagnosis—otitis media, a middle-ear infection. When her resident asked what treatment she'd recommend for the four-yearold patient, the first antibiotic that came to her mind was Augmentin. A few hours earlier, at a drug-company-sponsored lunch, she'd received a pen emblazoned with: "Augmentin: unsurpassed in the treatment of otitis media."

"So what happened?" asks Nierenberg. The resident agreed with the student and handed a prescription for Augmentin to the child's mother. But when the mother went to fill it, she discovered that the drug cost $80—and she had no insurance. Too embarrassed to ask for a cheaper medication, she never filled the prescription. Three days later, the child was admitted to the emergency room with bacterial meningitis—the worst-case consequence of an untreated ear infection. There's a 90% to 95% chance that a generic antibiotic, costing only $10 to $20, would have been effective, says Nierenberg. But doctors all over the country prescribe expensive, name-brand drugs instead of cheaper, often just as effective, generics. A long list of studies in prominent journals has documented that drugcompany marketing does alter physicians' prescribing practices.

Yet Nierenberg is not "anti-drug company," he asserts, just anti-gift. Not accepting drug-company freebies is one way to combat the rising cost of pharmaceuticals and promote affordable health care, he believes.

His commitment to these causes also extends into the community. For example, he volunteers regularly at the Good Neighbor Clinic, a free clinic that serves the Upper Valley. He recruits DMS students to volunteer there, too. On a recent busy evening at Good Neighbor, Nierenberg was helping a medical student and a resident think through each patient's condition before recommending a treatment. If a prescription was needed, he'd prompt them to consider a generic drug. "It's cheaper," he'd remind them. Doctors must do their part to keep down the cost of health care, he believes—whether by prescribing generics whenever possible or by rejecting that free, fancy pen.