Tutorials Give Students an Opportunity To Discuss, Diagnose Real-Life Cases

Eight people sit around a table, having an intense discussion about a diabetic patient experiencing complications from a pregnancy. Finally, one of them concludes, "Administer insulin and have her undergo a blood test."

No, this isn't the emergency room of Massachusetts General Hospital. But such decisions are made daily by Harvard Medical School students studying real-life cases in tutorials, a vital part of the school's New Pathway curriculum.

The New Pathway, established in 1985, emphasizes problem solving, the dynamics of the patient/physician relationship and smaller classes, rather than just rote memorization of medical facts.

One of the most distinctive components of the New Pathway curriculum is the tutorial, a class of eight students that brings together the concepts of small group learning and case study.

The two-hour sessions, which are held two or three times a week, begins when one of the students states the facts of a given case. The students then define the issues, and a student "expert" might discuss one of them.

Next, the group creates a list of possibile ailments given the symptoms, and students choose the one they think is most probable. In doing so, participants call upon a variety of sources, including texts, current periodicals and magazine reviews.

As the discussion progresses, the tutor produces sheets providing more information about the case, such as blood test results.

Throughout the discussion, the tutor only interjects when directly asked a question by a student or when it seems that students have a mistaken assumption that is leading them astray. The tutor is often a leading expert in his field and can offer information on the most current research, some of which he may have written.

The tutor also introduces "mini-cases" to drive home points made in completing the diagnosis and treatment of the initial case.

For example, in a recent endrocinology tutorial the students discussed a patient with thyroid problems. The class then examined the case of the sophomore at Harvard who visits the University Health Services because of fever, sore throat and ear ache. The diagnosis: a thyroid problem.

The informal atmosphere of the tutorial lends itself to freer discussion, but it also tends to keep the group on its toes. Students are generally well prepared for each session, and are quick to admit they don't know something rather than take a guess.

In the past, critics have questioned whether students learn the large amount of basic knowledge necessary to become a physician. However, Paul W. Winterton, a second year medical student, says, "Cases lend themselves to learning large amounts of theory." 10