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BY CHARLES CLAWSON

A two-week pilot exchange project involving medical students from Stanford and Sweden wraps up on Friday, having demonstrated similarities and differences in pharmacological approaches between the two countries as well as the effectiveness of a new, Web-based style of instruction.

The Internet-reliant course, created to teach diagnostic and research skills with a global awareness, has provided simulation of patients, links to Web-based medical resources and continued interaction after the Swedish students returned home. The PharmaPaC project, funded by the Wallenberg Global Learning Network, is a collaborative effort involving the Stanford University Medical Media and Information Technologies program (known as SUMMIT) and the Swedish Learning Lab at the Karolinska Institute.

The Swedish group, six medical students and one professor, were on the Stanford campus April 8-13 collaborating with a group of six Stanford students and one professor on medical cases with an emphasis on clinical pharmacology. The cases varied widely, from questions of what type of anesthesia to prescribe before operating on a badly sprained ankle, to the proper response to certain lung sounds. This week ­ the second week of the PharmaPaC project ­ the Swedish students are back home, chatting online with their Stanford teammates at designated times to discuss and resolve cases before review by their respective instructors.

Notably, the case-based course uses the Web rather than paper cases, allowing links to online resources (articles regarding study guidelines, landmark articles, key organizations, clinical photos, X-rays and digitized videos) and virtual-reality effects, such as the sound of a patient's heartbeat and lungs.

"Relying on the knowledge in a textbook won't be enough in the future because new information is coming so fast," said Carl-Olav Stiller, MD, PhD, clinical assistant professor at Sweden's Karolinska Institute. "A textbook is outdated as soon as it's published, basically. So you have to know how to access the huge amount of literature that is out there to know how to anticipate adverse effects and interactions with drugs and the like."

Lars Osterberg, MD, clinical assistant professor at Stanford and the faculty member involved in the project, underscored the importance of online instruction. "Web-based instruction is particularly useful as a transition for students to their clinical years and internships because they can practice without actually seeing a patient," Osterberg said. "We're doing as much as we can with the digital technology ­ students can listen to hearts and lungs and look at skin for signs of rashes. Also, normally as a student you hear about doing a pulmonary function test but you don't see one being done; through the Web, you actually see what your patient has to go through."

The project also has highlighted the differences ­ and similarities ­ in pharmacological approaches between the two countries. Stiller said one of the major differences involves the treatment of infectious diseases. "Swedish tradition has been to narrow the use of different antibiotics, even though they are available," Stiller said. "The first-line treatment for upper airway infection is still penicillin-based. Because of this policy the number of resistant strains in Sweden is quite low, whereas the United States has seen the development of more resistant strains and other infections as well."

First-line treatment for asthma also includes some differences; the Swedes primarily use a powder inhaler instead of an aerosol inhaler. Yet, the most pronounced distinctions in medical care are in the nature of the systems themselves.

"Our health care system is centralized, where it's easier to get new guidelines to primary care physicians," said Stiller. "In the U.S. you have all these health-maintenance organizations and different care providers, so it's harder to get large change in the treatment policy. Also, the pure number of available drugs is much greater in the U.S. because the Swedish authorities have been quite restrictive in allowing new drugs to the market if they haven't been shown to be better than the old ones."

Within the actual coursework of the case studies, students reported only minor differences in approach, suggesting that access to the same journals and resources has caused the world of pharmacology to shrink.

"There aren't very important differences in the treatments," said Linda Englund, a Swedish student, "but when you find a difference, it really stimulates you to look for why."

"The differences have been minor," agreed Laura Meinke, a Stanford student. "In Sweden, for example, they might take a different antibiotic for a respiratory tract infection than we do here, but that's just a matter of what's available. I think more than learning about how our countries are different, we've learned that despite the thousands of miles between us and the different structure of our medical care systems, treatment is very similar. And the goals of that treatment are very similar."

Swedish student Pål Winkrantz phrased the sentiment differently: "We already knew quite a lot, because we watch 'ER' in Sweden, too."

In June the course will be reviewed and refined to improve on the pilot program for next year. One suggestion that has already been made is to have students address cases via the Web throughout a full year of internal medicine.