David Nierenberg, M.D.: Pharm stand
By Jennifer Durgin
here are two sure ways to get pharmacologist David Nierenberg, ing. By the time he was 15, he had taken all the science courses that
M.D., fired up: take notes with a drug-company pen or mention
his high school in Chappaqua, N.Y., offered. So, in 1965, he enrolled
DMEDS, the Dartmouth Medical Encounter Documentation
in Phillips Academy, a boarding school in Andover, Mass. He then
System. The former rouses his ire, the latter his enthusiasm.
carried his passion for science to Harvard, where he earned a degree
On this particular day, he's teaching pharmacology to second-year
in biochemistry in 1971.
medical students. As the students suggest possible drug treatments for
He planned to go on to medical school but wanted a break from
two fictional patients, he pushes them to think through their answers
academic rigor. So he headed to Oxford on a Harvard fellowship to
step by step—from considering the symptoms and physiological mech-
work in a research lab. "Research has a very different tempo and feel
anisms of each condition to evaluating which drugs to prescribe.
than taking four or five courses every term," says Nierenberg.
The class "is supposed to be about pharm, but you can't really think
In 1972, he returned to Harvard for medical school. After com-
about drugs until you've thought
pleting his M.D., he did an in-
through the pathophysiology,"
ternal medicine residency at
Nierenberg believes that using pens and other freebies to
explains Nierenberg, who is also
Boston's Beth Israel Hospital and
market pharmaceuticals prevents doctors from being "clear-
senior associate dean for medical
a clinical pharmacology fellow-
education. He is conversational
headed about prescribing the drug that is most effective."
ship at the University of Califor-
with the students, sometimes hu-
nia at San Francisco (UCSF).
morous, but never condescending and always precise. It's clearly a
When the head of clinical pharmacology at UCSF became chair of
good approach: he's been awarded the Medical School's Clinical Sci-
medicine at Stanford, he asked Nierenberg to be his chief medical
ence Teaching Award twice, in 1986 and in 2000.
resident. In 1981, Stanford tried to entice Nierenberg to stay on by of-
After class, a few students linger to talk with him. As one asks a
fering him either of two positions—one that would be 90% research
question, Nierenberg reaches across the table to examine the con-
and 10% clinical and another 90% clinical and 10% teaching. But
tents of her purple pencil case. "You're not going to make me angry
Nierenberg had other ideas. "What I really wanted," he says, "was to
with any drug-company pens in there?" he asks. His mock glare is soft-
spend about a third of my time teaching, about a third of my time as
ened by his unruffled voice and quick grin. "No," she laughs. A fellow
a physician, and about a third of my time doing research." He and his
student had already warned her about Nierenberg's disdain for the
wife also wanted to move back to New England. One night, they won-
way many pharmaceuticals are marketed to physicians.
dered if Dartmouth might be the right place. They'd always enjoyed
"Good. Because I go into anaphylactic shock when I see drug-com-
visiting New Hampshire on long weekends and vacations. The very
pany pens," he says, feigning shortness of breath. Nierenberg is cre-
next day, out of the blue, Nierenberg got a letter from DMS. "It was
ative in the way he conveys his strong opinions about pharmaceuti-
literally the next day!" he says, still awed by the timing.
cal marketing. For example, he has a "dirty-pen swap," offering stu-
DMS needed someone with his kind of training to set up a division
dents a chance to turn in the free, often fancy, pens they get at drug
of clinical pharmacology, teach a new fourth-year pharmacology
company-sponsored luncheons and lectures for a "clean" pen.
course, and do whatever else that person wanted. Nierenberg accept-
"This is all voluntary and educational. I've never confiscated," con-
ed. To his surprise, what he enjoyed most was teaching and designing
tends Nierenberg. Is it true that he's broken some students' pens? He
courses. "Between 1981 and 1991, we developed the most intensive,
explodes with laughter. "Wow, that myth has grown."
best, required clinical pharmacology course, almost certainly, of any
But the dirty-pen swap is sometimes a tough sell. "See," he ex-
medical school," he boasts.
plains, "the drug companies hand out $7 or $8 pens" that are color-
ful, thick, and comfortable in one's hand. His are skinny, bright-or-
ange, 39¢ knock-offs that say "DHMC Clinical Pharmacology Rx:
n 1995, then-Dean Andrew Wallace, M.D., appointed Nierenberg
to the newly created role of associate dean for medical education.
Prescribe the BEST drug!"
Ever since, Nierenberg has been helping DMS move to the fore-
The message has great significance for Nierenberg. Teaching med-
front of medical education. Under his leadership, the school has re-
ical students how to prescribe the best medicines for their patients is
duced redundancy among courses; changed the ob-gyn rotation to in-
what got him interested in course design and educational administra-
clude general outpatient women's health; infused more clinical mate-
tion. But his interest in medicine goes back even further, to when he
rial into the first two years and more basic science material into the
was a kid and observed the work of his family internist. "That looks
clinical years; and established itself as a national leader in medical ed-
like a nice combination of service and science," he remembers think-
ucation and medical education research (see page 7).
"We are teaching stuff we didn't do 10 years ago," Nierenberg says.
Jennifer Durgin is
Dartmouth Medicine magazine's senior writer.
"Medical ethics, cultural competency, increased attention on com-
62 Dartmouth Medicine
munication skills, whole new cur-
search. She helped to develop
ricula on how the health-care sys-
ClinEdDoc, DMEDS's predeces-
tem works, how to work in teams,
sor, and has worked with Nieren-
how to try to improve what you
berg for 10 years. "He has been
very insightful about the evolu-
But to improve, one must first
tion of medical education," she
evaluate the status quo. Nieren-
says of her colleague. "He's always
berg's favorite tool for assessing
looking to improve it."
medical education is the Dart-
Carney is also familiar with
mouth Medical Encounter Docu-
Nierenberg's willingness to speak
mentation System (DMEDS),
out on issues he thinks are im-
launched in July 2004. He leans
portant. "Boy, if he really believes
forward in his squeaky office
in something, he stands there for
chair, opens the DMEDS data-
it," she says, in a way that suggests
base, and starts reading aloud
she's been on the receiving end
Dartmouth medical students know that if they use a free drug-company pen like this
from it: "Patient was mentally
of his resolve more than once.
one around pharmacologist David Nierenberg, he'll start to pitch his "dirty pen swap."
disabled. Much of the history was
And Nierenberg really be-
provided by a friend/employer. Patient was 52 years old and had nev-
lieves that using pens and other freebies to market pharmaceuticals to
er seen a doctor." This is just one among thousands of entries made
physicians is wrong. The "dirty" pens he collects from students are
by students about patient encounters during their clinical rotations.
relegated to a box on the crowded shelves of his lab. And on the top
"That's a really
powerful statement of how hard that student had to
shelf sits a larger box labeled "Hall of Shame," which contains such
work to find out what was going on with that patient," Nierenberg
doodads as a colorful "Ene-man" superhero advertising Fleet enemas
says. The data in the system is used in the aggregate to see what gaps
and a stuffed, talking "stuffy nose" embroidered with "Allegra-D."
there may be in students' experiences and to ensure consistency among
numerous clerkship sites.
Some of the inspiration for DMEDS, which Nierenberg helped de-
uch "crap," he says, is "getting in our way" and preventing doc-
tors from being "clear-headed about prescribing the drug that is
velop, came from his work in the late 1990s on a national committee
most effective for their patient, safest, and—all other things be-
that revised the U.S. Medical Licensing Exam. The committee con-
ing taken care of—least expensive." The idea that a trinket could al-
verted a multiple-choice section to interactive computer-based case
ter physicians' prescribing practices is pooh-poohed by some. But,
studies. Now, the exam presents fictional patients. Students can ask
Nierenberg asks, would drug companies spend billions of dollars a year
for the patients' histories, physicals, and lab-test results and then must
on marketing if it didn't work? "It's about name recognition," he in-
select diagnoses and treatment plans.
sists. "That's what's in a pen. It alters perspective."
Nierenberg reads another DMEDS entry: " ‘Patient's from Liberia
His favorite anecdote to illustrate this point is one that a fourth-
and spoke a different dialect of English.' This student had to learn to
year medical student wrote about for the clinical pharmacology course
rephrase questions in ‘a more simple and clear way to facilitate direct
he developed. In her paper, the student described the excitement of
communication,' " he explains. "That's an advanced
nailing her first diagnosis—otitis media, a middle-ear infection. When
skill. That's what we want our students to wrestle with before they go
her resident asked what treatment she'd recommend for the four-year-
out and be a doctor."
old patient, the first antibiotic that came to her mind was Augmentin.
Other medical schools have computer-based systems that record
A few hours earlier, at a drug-company-sponsored lunch, she'd re-
clerkship experiences. But Dartmouth appears to be the first to track
ceived a pen emblazoned with: "Augmentin: unsurpassed in the treat-
its students' acquisition of the competencies now required by resi-
ment of otitis media."
dency programs; it's expected that these competencies will soon be re-
"So what happened?" asks Nierenberg. The resident agreed with
quired of medical students, too. They cover six areas: medical knowl-
the student and handed a prescription for Augmentin to the child's
edge; clinical skills for patient care; interpersonal communication
mother. But when the mother went to fill it, she discovered that the
skills; professionalism; practice-based learning and improvement; and
drug cost $80—and she had no insurance. Too embarrassed to ask for
the ability to navigate a complex health-care system.
a cheaper medication, she never filled the prescription. Three days lat-
The fact that DMEDS is based on these competencies is "huge,"
er, the child was admitted to the emergency room with bacterial
says Patricia Carney, Ph.D., DMS's assistant dean for educational re-
continued on page 69
Dartmouth Medicine 63
Faculty Focus: Nierenberg
continued from page 63
meningitis—the worst-case consequence of
an untreated ear infection. There's a 90% to
95% chance that a generic antibiotic, cost-
ing only $10 to $20, would have been effec-
Margaret values her
tive, says Nierenberg. But doctors all over the
friendships. Whenever she
country prescribe expensive, name-brand
needs a ride, she knows
drugs instead of cheaper, often just as effec-
tive, generics. A long list of studies in promi-
she can count on her
nent journals has documented that drug-
friends to help. When she
company marketing does
needed high-quality eye
care, a good friend
Yet Nierenberg is not "anti-drug compa-
ny," he asserts, just anti-gift. Not accepting
drug-company freebies is one way to combat
Margaret is so pleased with
the rising cost of pharmaceuticals and pro-
the care she receives that
mote affordable health care, he believes.
she decided to be a good
His commitment to these causes also ex-
tends into the community. For example, he
friend to DHMC. She
volunteers regularly at the Good Neighbor
established a Charitable
Clinic, a free clinic that serves the Upper
Gift Annuity with funds
Valley. He recruits DMS students to volun-
from a matured CD. She
teer there, too. On a recent busy evening at
Good Neighbor, Nierenberg was helping a
liked the idea of having a
medical student and a resident think through
fixed income for life, a
each patient's condition before recommend-
charitable tax deduction, and knowing her gift will support
ing a treatment. If a prescription was needed,
medicine and research at DHMC. If you ask Margaret, she'll say
he'd prompt them to consider a generic drug.
"It's cheaper," he'd remind them. Doctors
she didn't do anything special. After all, that's what friends are for.
must do their part to keep down the cost of
health care, he believes—whether by pre-
scribing generics whenever possible or by
• guaranteed fixed income for life
rejecting that free, fancy pen.
• partially tax-free income
Alumni Album: Clark
• charitable tax deduction
• cash or appreciated assets may be gifted
continued from page 65
people about the worldwide AIDS crisis.
• income for one or two lives
Clark, who has received several national
Rates effective through
awards for his work, including the Annie
June 30, 2004
Dyson Award of the American Academy of
Pediatrics, is currently a fellow at the Center
Contact us today to learn more about this
for AIDS Prevention Studies at the Univer-
and other types of planned gifts.
sity of California at San Francisco. He and
Office of Gift Planning
fellow soccer players have returned to Dart-
mouth several times to help develop oppor-
Toll Free: 1-866-272-1955 • E-Mail: [email protected]
tunities for undergraduate and DMS students
to participate in Grassroot Soccer. And in
The Power of Partnership
November, he participated in a three-day
symposium at DMS on HIV/AIDS, "Great
Issues in Medicine and Global Health."
For all Clark's worldwide interests, getting
back to his own grassroots is nice.
Dartmouth Medicine 69
Cancer Causes Control (2014) 25:1131–1140 Serum levels of vitamin D, parathyroid hormone and calciumin relation to survival following breast cancer Linnea Huss • Salma Butt • Signe Borgquist •Martin Almquist • Johan Malm • Jonas Manjer Received: 3 January 2014 / Accepted: 5 June 2014 / Published online: 22 June 2014Ó The Author(s) 2014. This article is published with open access at Springerlink.com
More than twenty years ago, four college students asked each other: What if we could offer children from under-resourced communities individualized attention before they enter kindergarten, giving them the critical academic and social skills—the ‘jumpstart'—they need to succeed? The idea took hold and by 2015, Jumpstart had trained more than 40,000 college students and community volunteers, preparing over 87,000 children for kindergarten success. Jumpstart's program is replicated across the country in 14 states and the District of Columbia. We leverage partnerships with higher education institutions, Head Start, community-based preschools, and school districts to create sustainable solutions in order to close the kindergarten readiness gap.