Medical school curriculum



Second generation

12.27.05

‘What do future doctors really need to know?’

Creating a medical school curriculum for the twenty-first century

Medical schools often teach the basic sciences first, approaching diseases and organ systems from the molecular level up. Only after a year or more of coursework are students finally allowed to hone their clinical skills by working with real patients.

Emory’s School of Medicine plans to flip that model on its head. After all, says Professor of Physiology T. Richard Nichols, doctors first encounter a patient, not a virus or a cluster of abnormal cells.

“We decided to be creative about it and propose a new idea of giving medical students a conceptual coat rack on which to hang all of the information they receive,” says Nichols, who served on a committee charged with creating a groundbreaking new curriculum for the medical school. “We will start at the level of societal and environmental concerns, of public health, bringing some of the greater global issues into the educational process. Then, following some case presentations, we will begin teaching the framework of the human body—the behavioral level down through the major regulatory systems, the organ systems and how they interact—and finally what is happening at the cellular and molecular levels.”

In the fall of 2004, Dean Thomas Lawley issued a challenge to himself and others in the School of Medicine: to design a “bold and imaginative” curriculum that could serve as a model to medical schools worldwide and would use all of Emory’s strengths to produce “the type of graduates we desire.”

Revising the medical school’s curriculum began with a simple question: “What do future doctors really need to know?”

Lawley and Professor of Medicine Jonas Shulman, senior adviser for curriculum development, held discussions with chairs and course leaders and visited other medical schools, including Harvard, the University of California–San Francisco, and Stanford. A steering committee was established and town hall meetings were held with faculty and students.

“We wanted to graduate not only good doctors but also leaders in their field who are broadly trained and able to see new connections,” says Nichols. “We don’t want to kill creativity; we want to enhance it.”

Medical school curriculums traditionally are defined by two stages—basic science years (M1 and M2) and clinical years (M3 and M4). But in Emory’s new curriculum, which will be phased in beginning in 2007, basic sciences and clinical care will be “integrated throughout,” says Professor Carlos del Rio, co-chair of the steering committee.

The proposed medical school curriculum has four main components:

• “Foundations of Medicine” This fifteen-month phase would be heavily case-based, taught by both clinicians and scientists. Public and predictive health would be integrated throughout, and small-group problem solving would be emphasized. Clinical experience would be included from the start, and students would work in healthcare teams that might include nursing students or physician assistant students. Volunteer service would be expected.

• “Applications of Medical Sciences” This year-long phase would be divided into four or five major blocks, each preceded by a one-week intersession focusing on basic knowledge and clinical skills specific to the discipline. A scholarly approach to patient care and faculty/student interactions would be maximized. Students would spend time with clinical teams at Grady, the Veterans Affairs Medical Center, Emory University Hospital, or Crawford Long Hospital. Board exams would take place at the end of this phase.

• “Discovery” This five- to ten-month phase would be dedicated to scholarly pursuits, including basic research, clinical research, or public health research. Students will be able to choose to complete the discovery phase at Emory, at other facilities in Atlanta (such as the Centers for Disease Control and Prevention or the Carter Center), or at institutions such as the National Institutes of Health. A scholarly manuscript will be required, and students will be encouraged to present at national meetings and publish in peer-reviewed journals.

• “Translation of Medical Sciences” This four- to nine-month phase would include three required clinical rotations: a subinternship in medicine, pediatrics, surgery, or obstetrics and gynecology; an emergency medicine rotation; and a critical-care unit rotation. A mandatory “capstone course” would come after students are matched with their residency programs and would provide instruction in recent advances in medical science, focusing on the roles of a resident as student, teacher, and caregiver. The course would address working with other health professionals as well as medical, legal, ethical, and economic issues.

The new curriculum is highly collaborative, from inception to execution. Joint degrees such as the MD/MPH or the MD/MBA would continue to be possible, especially when combined with a fifth year of study.

“One of the most unique aspects of this curriculum is that it offers a highly individualized curriculum for every student,” Shulman says. “For example, let’s say one student is interested in intra-urban care and begins working at a clinic and taking courses within the School of Public Health. Or a student is interested in vascular biology and spends time in the lab, perhaps even going for a Ph.D.”

Close contact with faculty members is an integral part of the curriculum, through both mentoring and observation in a clinical setting.

“You learn professionalism by example,” says Associate Professor William Eley, an oncologist at the Winship Cancer Institute and associate dean for medical education. “We want students to keep high on their radar that we are a place that treats patients humanely. The relationships built between doctors and patients are essential to the joys of medicine.”

The curriculum’s case-based approach to teaching, Eley says, is the best way for students to remember the massive amounts of information they are expected to retain.

“Medical knowledge is increasing exponentially. No one could keep it all in their brain,” he says. “But talk to physicians, and they’ll remember patients they saw twenty-five years ago and talk about their case as if it were yesterday.”

Kate Heilpern, assistant dean of student affairs and associate professor in emergency medicine, says, “medicine is transitioning from a paternalistic view to a more inclusive, collaborative approach.” A new curriculum is vital “if we want to skate where the puck is going.”

Service to the community—be it global or local—is emphasized. All students will spend at least three weeks providing care to people without access to health services.

“Whether that means participating in a medical clinic in rural Georgia or in rural Uganda . . . the students aren’t just observing, they are part of the process,” says Assistant Professor Neil Lamb of the Department of Human Genetics. “It’s just a tantalizing taste of the benefits and responsibilities of working with underserved populations. Hopefully, they will continue this type of work.”

The timing of the proposed switch to the revised curriculum coincides with completion of the new, $55-million medical education building, which is currently under construction and is set to open in June 2007.

“We are at a place in the history of our school where we have everything it takes to create a new standard for medical education—not just here at Emory, but throughout the world,” Lawley says. “We can change the trend from pouring as many facts as we can into our medical students and then expecting them to pour them back out in examinations, to allowing the patients to ignite a sense of excitement and discovery in them and us as we bring together the art and science of medicine.”—M.J.L.

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