CH 107
Science and Practice of Medicine
− Syllabus Fall 2014 −
Professor
Richard Glickman-Simon, MD
Department of Public Health and Family Medicine
617-636-3640
richard.glickman-simon@tufts.edu
Meeting Times
Wednesday, 1:20 – 4:20 pm
Office Hours
Wednesday, 11:00 am – 1:00 pm (by appointment) @ Brown & Brew
eTexts
Required: Loeffler A. Introduction to Human Disease: Pathophysiology for
the Health Professional, 6e
Optional: Cohen BJ. Memmler’s Human Body in Health and Disease, 12e
Course Description
This course is an introduction to biomedical science and its application to clinical medicine. This
is not a course in anatomy and physiology or pathology. Nor is it simply a course about what
doctors do for a living. Rather, it is a critical investigation of how doctors think about their
patients, make decisions on their behalf, and gauge the success of their interventions. It is an
exploration of the uneasy and oftentimes obscure relationship between medical science and
medical practice.
One of the greatest challenges in the practice of medicine is the inescapable contradiction
between the objective nature of biomedicine and the subjective experience of health and
disease. Clinical medicine is principally a scientific endeavor, but it is also a human enterprise,
fraught with uncertainty, intuition and pain. Although most physicians enthusiastically embrace
science and technology in the service of their patients, they struggle with the inevitable gap
that separates the science of medicine from the art of healing.
One way medical educators attempt to address this incongruity is by removing students from
the classroom as soon as possible, affording them ample opportunity to work directly with
patients and apprentice for experienced clinicians. Since we have no access to real patients,
we’ll use virtual cases and one another as worthy substitutes. By the end of the course, you will
have a better understanding why physicians make the decisions they do and how they reconcile
the interests of their patients with the principles of their science.
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The course is organized into three interdependent sections:
I.
The Science of Medicine. Physicians base many (but not all) of their decisions on research
findings and well-established biomedical principles. In an effort to understand the
rationale behind these decisions, we will spend some time discussing the fundamentals of
health science, including the pathophysiology and epidemiology of disease.
II.
The Practice of Medicine. Clinical practice, more or less, follows a prearranged script that
begins with the patient interview and ends with the treatment outcome. We will
sequentially act out this drama by taking histories, “performing” physical exams,
interpreting test results, prescribing treatment and modifying lifestyles.
III. The Science and Practice of Medicine. Here, we apply what we learned in the previous
two sections to the diagnosis, treatment and prevention of four prevalent medical
conditions: cardiovascular disorders, cancer, infectious disease and inflammatory
disorders. These conditions are ideal for our purposes because of their high morbidity and
mortality, preventive potential (in some cases), social impact, and scientific interest. We
will also consider where physicians fit in the wider health care system how this influences
the care of patients.
Learning Objectives
By the end of the course, you will be able to:
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Define health, disease and illness and describe the approach physicians take to their
preservation, management or cure.
Illustrate the basic organization of the human body including the structure and function of
the major classes of organic molecules, cells, tissues and selected organ systems.
Describe the primary pathophysiologic mechanisms and their relationship to the etiology
and risk of disease in humans.
Describe the etiologies of disease and distinguish between the concepts of risk and
causation.
Describe the hierarchy of medical evidence and characterize the unresolved tension
between evidence-based medicine and clinical practice.
Explain the scientific rationale behind medical decision-making and identify major factors
affecting those decisions.
Discuss the relevant professional, ethical and interpersonal parameters that define the
patient-physician relationship.
Describe the common diagnostic, treatment and preventive interventions and the principles
governing their clinical application.
Collect, organize, interpret and communicate medical information on a specific topic.
Explain the epidemiology, pathophysiology, clinical manifestations, diagnostic evaluations,
and management options for four common medical conditions.
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Student Responsibilities
Reading Assignments
All reading materials for this course are available electronically, either on Trunk
(https://trunk.tufts.edu) or in the e-text:
Loeffler A. Introduction to Human Disease: Pathophysiology for the Health Professional, 6e.
(ISBN – 9781284034660)
A customized version of the text, including only the chapter we will be covering, has been
prepared. The access code and instructions are available at the bookstore. However, you may
rent or purchase the entire text if you’d prefer (see instructions below).
If you have never taken a college-level course in human physiology, I recommend buying or
renting an additional e-text (optional for this course):
Cohen BJ. Memmler’s Human Body in Health and Disease, 12e. (ISBN – 9780781765770)
To rent these texts, click on the respective titles and following the instructions:
 Introduction to Human Disease: Pathophysiology for the Health Professional, 6e
 Memmler’s Human Body in Health and Disease, 12e
Audience Response System
We will be using Learning Catalytics during most of the sessions. This system allows you to
respond to questions anonymously during class using any mobile device. Please be sure to
register for access prior to the start of Session 2 on Sep 10. Go to:
https://learningcatalytics.com/student_sign_up
and follow the instructions. If you already have an active account, there is no need to register
again for this course. One account gives you access to unlimited courses for that time period.
Clinical Diagnosis Project (CDP)
The CDP includes a patient portrayal video, a differential diagnosis paper, and an in-class history
and physical exam exercise. To get started, choose any three medical conditions that interest
you from the Diagnosis Options list, which can be found on Trunk under Assignments > Session
2. (Note: you can view these diagnoses from A-Z or by subcategory.) Illnesses that you or a
close family member has experienced would work well but are not necessary. If you do choose
a diagnosis from your personal or family history, be sure you’re comfortable disclosing it in
public. To submit your 3 choices in order of preference complete the survey found at:
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https://docs.google.com/forms/d/1lVCjyRwfLPEcSLFEuwRadgbr9x82kLJqXezPXcgAbR4/viewfor
m?usp=send_form
by 1:00 pm on Sep 10. I will assign you one of the diagnoses and inform you via email by Sep
17.
Once you have your diagnosis, you are to prepare the role of a “patient” suffering from this
condition for the History and Physical (H&P) Exercise during Session 7 (Oct 15). For the sake of
this assignment, assume that your character has never seen a health care provider in the past
for this problem. This means that your portrayal should not include the results of diagnostic
tests or previous treatments.
Patient Portrayal Video
The purpose of this first CDP assignment is to help you prepare your patient character. The
Overview of History Taking and the Physical Exam document (linked to Session 6 Assignments
on Trunk) is a good place to start. Your task is to create a realistic case of a patient suffering
from your assigned condition. To do this, you will need the following information:
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Risk factors - known or theorized genetic predispositions (family history), environmental
exposures (e.g., neighborhood, occupation), social circumstances (e.g., stress, poverty)
and/or health behaviors (e.g., diet, exercise) that increase the chances of acquiring your
condition
Clinical presentation - signs and symptoms associated with a typical, moderate case of your
condition; this includes findings from both the history and physical exam if applicable
(which is usually the case)
With this information in hand, create a 5-10 minute video of a clinical visit in which a
“physician” (on or off-camera) is taking your history. You must personally portray the patient.
Be as creative and realistic as you possibly can! At the very beginning of your video (before
assuming the role of your character) be sure to clearly state your actual full name and your
patient’s diagnosis. A real patient is usually unable to discuss physical exam findings with his or
her physician. To include this important information in your video, therefore, it will be
necessary for you to step out of role at the end and describe what the physician found on exam
(if anything). Remember, there is no need to include diagnostic tests or treatment
interventions. Since this is your first visit to a clinician, you do not have access to this
information.
Save your CDP video using one of the following formats (only) – .mov, .mp4, or .wmv – on your
computer and submit it on Trunk under Assignments > Session 7 by 1:00 pm on Oct 15
(extensions not permitted). If for some reason, Trunk will not accept it, you may email it to me,
or use Dropbox. At the end of the course, we will screen 3 or 4 nominees for the best patient
portrayals, and vote as class on who should receive the Oscar.
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History & Physical Exercise
At the start of Session 7, you will pair up with a random classmate who, disguised as your
physician, will take a detailed history and perform a mock physical examination on you. It is
essential that you come prepared with all the information necessary to be a cooperative,
informative and realistic patient. This is the main purpose of your patient portrayal video. If,
however, your physician poses a question you cannot confidently answer, don’t make
something up. I will serve as an “expert” consultant to fill in any gaps.
Important
Do not disclose your diagnosis at any time to your
“physician” or anyone else
As the physician, it will be your turn to conduct the clinical evaluation. Since your patient (most
likely) will not have the condition in question, he or she will orally provide you with physical
exam findings when asked (so be sure to ask!). Do not simply say, “Are there any abnormal
physical exam findings.” Instead, go through the exam step-by-step as it appears in the
Overview of History Taking and the Physical Exam document. Your patient should report a
value (e.g., BP 140/100 ) or provide a description (e.g., decreased breath sounds in the left
lower lung field) when specifically asked about each component of the exam (e.g., vital signs
and pulmonary exam respectively). You will have about 20 minutes to complete your
evaluation.
Case Diagnosis Paper
For the second CDP assignment, you are to take the data you collected as the physician and
write a short paper in which you develop a differential diagnosis, order diagnostic tests (if
necessary), and arrive at a final diagnosis. Divide your paper into four sections with the
following headings (approximate lengths):
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Case synopsis. (½ page) Briefly describe the most relevant clinical findings from your
evaluation. Be sure to avoid extraneous information having no direct bearing on the case;
however, do not forget about pertinent negatives (e.g., no history of abdominal surgery in a
patient presenting with abdominal pain). When discussing the physical exam, be sure to
report actual values for vital signs and fully describe all relevant findings (rather than simply
writing, for example, “abnormal”). Do not include normal findings superfluous to your
differential diagnosis (DDx).
Differential diagnosis. (1 page) List at least three hypothesized diagnoses and provide a
one-paragraph rationale for the inclusion of each based on the data you collected.
Diagnostic work-up. (1 page) Propose diagnostic tests you would order to help narrow your
DDx and provide a brief justification for each, taking into account their risks (e.g.,
inaccuracies, adverse effects) and costs. Be as specific as possible (e.g., do not simply write
“blood work”, but specify exactly which blood test(s) you mean). Don’t be wasteful – order
only those tests necessary to make a proper diagnosis. In some cases, diagnostic testing will
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not be necessary. If this is the case, be sure to explain why. Remember that diagnostic
tests include not only blood work or imaging studies, but they can also include detailed
questionnaires (e.g., neuropsychiatric testing for mental disorders.)
Final diagnosis. (1-½ page) Identify and justify your patient’s most likely diagnosis given the
clinical information you collected (from the history and physical exam) and results of any
diagnostic testing you ordered. Since you can’t actually run these tests, you will need to
make up results that are supportive of your final diagnosis and unsupportive of the other
possibilities in your DDx. Again, be sure to provide actual values or descriptions.
Submit your CDP paper on Trunk under Assignments > Session 11 by 1:00 pm on Nov 12. It
should be 2.5 – 4 single-spaced pages (≥12-pt font), and include at least 4 different references
(not included in page limit).
Case Management Project (CMP)
For the case the CMP, you will diagnose and treat a patient with one of 12 selected chronic
conditions. To do this, you and 3 other students will team up to produce and realistic, clinical
vignette complete with initial symptoms, history and physical exam, diagnostic testing,
therapeutic interventions and final health outcome. Each group will perform its vignette for the
rest of the class during Session 9 – 12. The condition portrayed will coincide with the topic of
the day:
Session
9
Topic
Cardiovascular Disorders
10
Cancer
11
Infectious Disease
12
Inflammatory Disorders
Possible Conditions
Acute coronary syndrome (angina or MI)
Stroke
Peripheral vascular disease
Breast
Prostate
Colorectal
HIV / AIDS
Tuberculosis
Hepatitis C
Rheumatoid arthritis
Multiple sclerosis
Alzheimers dementia
Up to 3 groups will perform per session. We will form groups, assign directors, and choose
conditions during Session 4 on Sept 24.
Each 30-minute performance must include at least 4 of the following characters:
 Patient (required)
 Primary care physician (required)
 Patient’s family member, friend or co-worker
 Emergency medical technician
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Pathologist
Pharmacist
Physical, occupational or speech therapist
Psychologist
Radiologist
Specialist physician
Group members may portray more than one character, and all should be given roughly the
same number of lines. Try your best to memorize your lines prior to the performance, but this
is not required. Consulting note cards is permitted.
After choosing your condition, your first task will be to write a draft screenplay, which should
include the following information:
Case – Briefly describe the patient’s story from beginning to end, including history and physical
exam findings, diagnostic test results, final diagnosis, treatments and final outcome (e.g., return
to symptom-free normal function, continued dysfunction, death).
Cast – List the characters in your scenario and briefly describe their respective roles.
Scenes – Identify each scene by title and number (e.g., Scene 1 – Patient Eating Breakfast) and
briefly describe what takes place. There should be a minimum of four scenes, one of which
must portray the initial encounter between the patient and primary care physician.
Props – List the various props and/or costumes you will use. Each character (including the
patient) must posses at least one identifying prop or costume so the audience knows who he or
she is supposed to be (e.g., white coat for physician, medication bottles for pharmacist).
Have one member of your group submit a 2 – 3 page, single-spaced draft on Trunk under
Assignments > Session 6 by 1:00 pm on Oct 8. No references are required for this draft version.
At the end of the session, I will meet with each team for 5-10 minutes to go over your
screenplay and make suggestions. The final screenplay is due by 1:00 pm on Oct 29 irrespective
of when you will be performing (submit on Trunk under Assignments > Session 9). It should
also be 2 – 3, single-spaced pages and include at least 4 references this time around (outside
the page limit).
CMP evaluations will be based almost entirely on group performances rather than written
screenplays. Every member of the group receives the same score.
Online Quizzes and Exam
There will be two online quizzes and a comprehensive final exam, all open book and notes.
Although you may use any written resource you wish to answer the questions, I strongly
suggest you stick to the material covered in the course. You may not consult with other human
beings, including classmates during or after the quizzes or exam. You will have 45 minutes to
compete the 15-question quizzes and 2 hours to complete the 40-question exam, each
consisting of multiple choice and short answer questions. Quizzes and exams will be open and
available to take on the dates and times listed below:
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Quiz 1
Quiz 2
Exam
Date
Sep 29
Oct 27
Dec 11
Time
3 – 9 pm
3 – 9 pm
12 – 9 pm
Sessions
1-4
5-8
1 - 12
Notes on Papers and Video
Sources / Citations. Since the reliability (accuracy and timeliness) of information available on
the internet varies considerably, it is best to rely exclusively on peered-reviewed literature for
all your assignments. Peer-reviewed sources include textbooks, most journal articles, and
databases subscribed to by the TUSM Health Sciences Library
(http://www.library.tufts.edu/hsl/). They do not include websites whose addresses end in:
.com, .org or .gov. Some of these may be useful places to start your research, but you should
not cite them in your CDP paper or CMP screenplay. For the CDP paper, numbered citations
(imbedded in the text) are essential. I’d suggest avoiding footnotes since they take up space on
each page, but all numbered citations should appear on a bibliographic page (not included in
the page limit). For the CMP screenplay (final version only), a list of references will suffice;
imbedded citations are not necessary. There is no need to submit references with your CDP
video.
Authorship. It is always best to avoid cutting and pasting content from any other source
directly into your paper. However, if you choose to do so, it is essential that you provide proper
attribution, including quotation marks and accurate, detailed citations. Failure to do so may
constitute plagiarism, in which case you will receive an automatic score of zero on the paper
and will jeopardize a passing grade for the course.
Evaluation. Your CDP video and CMP clinical vignette will be evaluated using three criteria:
accuracy/completeness (60%), production quality (20%), and realism/creativity (20%). Your
CDP paper will be evaluated using two criteria: accuracy/completeness (80%) and writing
quality (20%). Be sure to remove all grammatical and typographical errors before submitting
your papers.
Extensions. You may have a 48-hour extension on your CDP paper without a score deduction
as long as I approve your extension request prior to the due date/time. Without prior approval,
or after 48 hours with approval, 1 point will be deducted for each additional day (including
weekends) your paper is late. No extensions are permitted for the CDP videos and CMP
screenplays (draft or final).
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Grading Policy
Final grades are curved based on a mean score = B. Points are distributed as follows:
Assignment
CDP Video
CDP Paper
Case Management Project
Quizzes x 2
Exam
Total
Points
15
20
15
20
30
100
Extra Credit
You will not have the option to redo any work or submit additional work for extra credit.
However, 2 extra credit points will be awarded to tournament and Oscar winners.
Course Schedule
Ssn
Date
Topics / Events
Assignments / Notes
1
Sep 3
Course Introduction
Why We Get Sick
SYTYCD Opening Round
2
Sep 10
Injury, Inflammation & Repair
3
Sep 17
Hyperplasia & Neoplasia
4
Sep 24
Genetic & Developmental Diseases
5
Oct 1
Thinking Like a Doctor: Clinical Reasoning
& Evidence-Based Medicine
6
Oct 8
Diagnosing Disease I: History &
Physical Exam
Readings
 Human Disease text: Chp 1,2
 (Optional) Human Body text: Chp 1-3, Chp 4 (p 60-72), Chp 13
(p 286-97)
Readings
 Human Disease text: Chp 4
 (Optional) Human Body text: Chp 5 (p 84-90), Chp 16, 17 (p
378-90)
Diagnosis options due
Readings
 Human Disease text: Chp 5
 (Optional) Human Body text: Chp 4 (p 72-6)
Readings
 Human Disease text: Chp 7
 (Optional) Human Body text: Chp 25
Form groups and pick conditions for CMP
Readings
 Merck Manual – Special Subjects > Clinical Decision Making:
Introduction, Evidence-Based Medicine and Clinical Guidelines,
Clinical Decision-Making Strategies, Cognitive Errors in Clinical
Decision Making
Readings
 Overview of History Taking and the Physical Exam
 Human Disease text: Chp 3
CMP draft screenplay due
11
Ssn
Date
Topics / Events
Assignments / Notes
7
Oct 15
H & P Exercise
Diagnosing Disease II: Testing &
Screening
8
Oct 22
Managing Disease: Treatment &
Prevention
9
Oct 29
Cardiovascular Disorders
Clinical Vignettes
10
Nov 5
Cancer
Clinical Vignettes
11
Nov 12
Infectious Disease
Clinical Vignettes
12
Nov 19
Inflammatory Disorders
Clinical Vignettes
Readings
 Merck Manual – Special Subjects > Clinical Decision Making:
Testing
 Merck Manual – Special Subjects > Principles of Radiologic
Imaging (all sections)
CDP video due
Readings
 Merck Manual – Clinical Pharmacology > Concepts in
Pharmacotherapy (all sections)
 Bodenheimer T. Prevention of Illness in Understanding Health
Policy: A Clinical Approach.
Readings
 Human Disease text: Chp 8, 9
 (Optional) Human Body text: Chp 14, 15
CMP final screenplay due
Readings
 Human Disease text: Chp 6
 (Optional) Human Body text: Chp 4 (p 72-6)
Readings
 Human Disease text: Chp 11
 (Optional) Human Body text: Chp 5 (p 90-109)
CDP paper due
Readings
 Human Disease text: Chp 11
 (Optional) Human Body text: Chp 17 (p 391-7)
Nov 26
Thanksgiving Break
12
Ssn
Date
Topics / Events
Assignments / Notes
13
Dec 3
Course Review
Patient Portrayal Academy Awards
SYTYCD Finale
Extended Office Hours
Readings
None
Dec 10
B & B 10 am – 2 pm
Selected Resources
Lippincott. Handbook of Signs & Symptom (2010) 4th Ed
http://library.tufts.edu/search/t?SEARCH=Handbook+of+Signs+and+Symptoms&searchscope=1
Collins, D. Differential Diagnosis in Primary Care (2008) 4th Ed
http://library.tufts.edu/search/t?SEARCH=Differential+Diagnosis+in+Primary+Care&searchscop
e=1
Williamson M, Snyder L. Wallach’s Interpretation of Diagnostic Tests (2011) 9th Ed
http://library.tufts.edu/search~S1?/tInterpretation+of+Diagnostic+Tests/tinterpretation+of+dia
gnostic+tests/1%2C2%2C7%2CB/frameset&FF=tinterpretation+of+diagnostic+tests&4%2C%2C4
/indexsort=Stern C. Symptoms to Diagnosis: An Evidence-Based Guide (2010) 2nd Ed
http://accessmedicine.com.ezproxy.library.tufts.edu/resourceTOC.aspx?resourceID=690