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Excerpt
Drs. Marik and Kaufman have suggested that it is important to teach medical students higher cognitive skills such as interpreting physical signs, formulating differential diagnoses and developing management strategies.
I completely agree and our course was designed and implemented to achieve those same objectives. It was not designed to be a ``crash course'' or a ``mini-fellowship,'' but rather a clerkship where students could learn skills necessary to succeed by doing. Teaching at the bedside was not the issue. Our goal was to give students an opportunity to learn the basic cognitive and motor skills necessary to begin functioning as physicians at the bedside. We have outcome measurements to demonstrate achievement of this goal.
Since most students will rotate through intensive care units (ICUs) during their residency, we believe it is necessary that they have an understanding of the physiology, technology, pharmacology, and ethical issues they may encounter during those rotations. It was not our intent to have students spend a month in the ICU watching critical care physicians at work. Instead, we set out to provide students with the knowledge and skills necessary to become integrally involved in patient care. To this end, we developed interactive conferences and technical skills laboratories. We agree that these conferences and laboratory skill sessions would have been inadequate on their own; therefore, students were given the opportunity to take these skills directly to the ICU. Under close faculty supervision, students became active participants in patient care. They did not simply ``manage ventilator patients or insert pulmonary artery catheters,'' but stood at the patient bedside where they were able to observe improved cardiac contractility as they improved preload or added inotropic support. They were able to change ventilatory parameters and observe the effect of positive alveolar pressure on venous return and cardiac output.
Our goal was not to create a specialist through a 1-month elective. All students must learn to recognize patients who may require acute respiratory or cardiovascular support. They need to learn to prioritize patient problems and must be able to begin resuscitation since they may be taking care of unstable patients in outpatient clinics, on the wards, or in radiology suites until a critical care physician can assist. Students must also develop ethical decision-making and communication skills. This course provided exposure to the ethical principles that guide decision-making and to physicians discussing end-of-life issues with patient families. We strongly disagree that having students learn these skills is demeaning either to the specialty or its practitioners.
Paul L.
