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Reform School
After rolling out of its first major curriculum reform in a generation, Harvard Medical School receives a report card.
by Rich Barlow

It was the final exercise of the course that made Aretha Delight Davis ’10 think of her father’s terminal cancer. That exercise  ended a two-week introduction to Harvard Medical School’s first curriculum reform in a generation. Traditionally, cadavers serve as incoming students’ initiation into medicine. Last August, though, Davis’s class had been greeted by Introduction to the Profession, a short course that sent the students on rounds and gave them glimpses into the lives of working physicians, from interviewing patients to role-playing as part of a medical team responding to emergencies. To cap this early immersion into medicine, the professor asked the students to write a letter to themselves as just-graduated doctors, four years hence.

Davis had chafed at the course’s summer start; she’d worked in her former job right up to the beginning of school. Her skepticism spiked when the precourse readings included such selections as The Spirit Catches You and You Fall Down, a recounting of a Hmong family’s culture clash with U.S. medicine. “I’d dealt with similar conflicts in my former life as a lawyer,” she says, “and I felt like I’d been there and done that.” Yet the glimpses of healing she’d seen during the course had revealed medicine’s compassionate core—and banished her skepticism of the course’s value.

Now, addressing her future self, she wondered whether her father could beat his cancer long enough to see her graduate. Would the time-devouring demands of her studies trump keeping in touch with him and others who mattered to her? If that happens, she wrote in her letter, be sure to reconnect, so a sense of emptiness doesn’t degrade your work as a doctor.

Then, oblivious to the 200 students surrounding her in the lecture hall, she wept.

Davis’s emotional burden may well have mirrored the curricular one she was assuming. It has since been universally acknowledged that the revised first year of the new curriculum made the academic load that Harvard medical students traditionally shoulder heavier than ever. That’s partly because of new course requirements and partly because the coursework covered during the first two years of classroom instruction needed to fit into a shorter timeframe. For the Class of 2010, the clinical clerkship, radically remade in the new curriculum, will begin in May rather than July of their third year. The reforms also recast the old courses, redistributing their content and rearranging the order in which the content is presented.

The sifting and winnowing being done at HMS aims to produce a curriculum that better prepares student doctors to meet the needs of today’s patients. It may also provide the seed for a new generation of medical education reforms that will take root throughout the country.

Form Follows Function

In September 2001, the HMS Faculty Council convened its first meeting of the academic year. The rainy weather outside matched the somber mood indoors, as Joseph Martin, then dean of the School, requested a moment of silence for those who had died in the recent terrorist attacks. Council members then got down to business. Martin announced that the School would be taking a prolonged look at itself in preparation for an accreditation visit, almost two years away, by the national Liaison Committee on Medical Education.

Nine internal study committees set about dissecting every aspect of the School’s operation. Before members of the accreditation committee had even made their travel arrangements to Boston, the self-review had uncovered a key shortcoming: the quality of the clinical clerkships was uneven.

Many were excellent, the committee found. “What was problematic,” says Jules Dienstag, dean for medical education, “was how medicine itself had changed.” Treatment breakthroughs coupled with managed care had cut hospital admissions and lengths-of-stay. Since their development almost a century ago, the clerkships had placed students in hospitals. Yet as working physicians know, hospitals are no longer the best places to witness the evolution of a patient’s illness. Also, because the programs were designed to introduce students to different specialties by rotating the students through teaching hospitals, the clerkships didn’t allow students an opportunity to build long-term clinical care relationships with patients. For that matter, they didn’t spend much time with the School’s faculty; in hospitals, residents do most of the teaching.

“The faculty and the students had become more and more isolated from one another,” says George Thibault ’69, director of the Academy at Harvard Medical School, an organization founded to improve the School’s teaching. “The pressure on the faculty to do clinical care and research was rupturing the teacher–student bond.”

In addition to reviewing the need to revise the clerkships, Thibault says, the School’s self-assessment identified a pervasive lack of integration within the curriculum. Professors described courses as silos, each standing alone, with instructors not knowing the contents of their peers’ courses. And students groused that some courses were dishing out second helpings of material they’d studied previously. Establishing an integrated curriculum would also be vital to bridging the gulf between the first two years of basic science and the second two years of clinical instruction; with no immediate application, students would forget some of the science from their classroom work by the time their clerkships began.

While the directors of the various courses mapped out the curriculum for the first and second years, says Dienstag, “The faculty did something they’d never done before: They got together to coordinate what they taught. In the past, even people teaching the same course didn’t necessarily compare notes.”

It wasn’t always that way. Ronald Arky, a professor of medicine who has taught at HMS for more than four decades, recalls some flirtations the School has had with integration throughout his tenure. But success breeds complacency, which in turn breeds institutional amnesia, says Arky, and as HMS continued to top national rankings as a sterling example of medical education, the benefits of faculty communication were forgotten. The curriculum reform seems to be jogging that institutional memory.

Striking a Balance

One force behind the curriculum reform has been the observation that everything from doctors’ biases to the way health care is financed has a direct effect on how, or even whether, patients receive care. To help compensate, tutorials are now introducing students to the concept of culturally competent care; they address the concern that preconceived notions about a patient’s race, class, age, sexual orientation, or even health habits can skew the care that doctors deliver.

In the first year of the program, dubbed the New Integrated Curriculum, making a better doctor also means connecting the science of medicine with the sociology of medicine. Courses that had once been electives—such as medical ethics and social medicine—are now required. These courses further the integration concept by exploring the ethical and cultural aspects of some of the basic science that other courses present.

“I found it shocking that previous classes weren’t required to study ethics,” says Peter “Rocky” Samuel ’10, who sat on a committee of students, faculty, and administrators that met regularly to take the pulse of the new curriculum as the school year unfolded. “I was blown away by all the possible dilemmas out there, the many ways that ethics affect physicians’ professional lives.”

One case study posited a situation in which a newborn was en route to a hospital and in need of life-sustaining extracorporeal membrane oxygenation, or ECMO. The hospital’s three ECMO machines were in use. Should the staff turn away the newcomer or remove one of the babies already hooked up?

“The idea that you might be forced to make such decisions was new to many of us,” Samuel says. “We go to medical school to learn to give treatment, not to take it away.” After the instructor presented the percentages of survival, on and off the machine, for all four babies, the students weighed the various options—and found themselves disagreeing with one another. By presenting the reality of care rationing so starkly, the exercise forced the students to hone their ethical arguments.

“It may be satisfying to say, ‘I like Choice A because it’s the right choice ethically,’” Davis says. “But if you’re going to advocate for a particular position, you must have some baseline understanding of the ethical implications of that position.”

Course Corrections

Curriculum reform is an organic creature, one that evolves as circumstances change. Any number of needed tweaks became apparent after the inaugural year. The frenzied pace of the courses, for example, left many students sleepless in Boston. “My sleeping schedule certainly was curbed this past year,” Davis says. “And I’m saying that as someone who used to work long hours billing clients in six-minute increments.” By the end of the first semester, and certainly by the second semester, though, the students had adjusted to the intensive curriculum and learned how to manage their time.

Other student concerns centered on specific courses they felt lacked structure or assumed a level of scientific knowledge they hadn’t yet acquired. “I was learning random facts that might help me compete on ‘Jeopardy!’ but I couldn’t imagine how they were going to help me become a clinician,” says Davis. Those problem classes will be reworked, administrators vow, a promise reflected in the role of the committee on which Samuel serves. “The administration,” he says, “has monitored the class’s experience every step of the way.”

Despite the added work that the new courses entail, early returns on the reformed first year are encouraging. The old curriculum’s course on clinical epidemiology, for example, had drawn poor student ratings year in and year out, according to Dienstag. Yet its reconfigured successor has earned enthusiastic reviews.

Call to Order

A greater integration of second-year course material hopes to prompt similar raves from the students. “A morning presentation on the changes in respiratory and lung physiology,” Arky says, “is now followed in the afternoon by one on a drug-resistant tuberculosis epidemic in Russia. We’ve never had that sort of coordination before.”

Second-year pathophysiology exemplified the old curriculum’s failure to integrate topics. Students studying the gastrointestinal system, for instance, could ponder the case of a patient with chest pain, yet fail to consider that the person might be having a heart attack: We’re studying GI, not the heart, right? The new curriculum remakes pathophysiology into the yearlong Human Systems course, in which instructors in the different specialties will cultivate those connections.

The reformed curriculum also rejiggers the order of instruction. A key example: Pharmacology, taught over five weeks in the first year of the old curriculum, becomes a two-week block kicking off the second year. Follow-up courses in Human Systems will build on the pharmacological principles the students have learned. Delaying pharmacology until the second year is based on a simple premise: Students find it easier to learn about disease-curing drugs if they know something about the disease.

Human development—the changes that are necessary to a person’s healthy maturation—used to be scattered among different classes; the curriculum now has a full course on the subject in the second year. And in a change affecting both the first and second years of education, tutorials have been revamped to grow progressively more challenging, reflecting students’ advancing knowledge and skills.

Everything Old Is New Again

HMS has averaged one curricular makeover roughly every two decades since the Eisenhower era. The last overhaul, the New Pathway of the mid-1980s, wrought major changes in the first two years of medical education, with a tutorial-centered, case-based program replacing the lecture-heavy curriculum. Almost all of these reform efforts have shared one constant: to better mesh what’s taught in the classroom with what’s taught in the hospitals.

It’s not as balanced an equation as it might seem. Patient care and research have long outranked the classroom in Boston. In addition, teaching stipends for the School’s hospital-based doctors have varied tremendously. “Many faculty members didn’t even receive remuneration,” Thibault says. “And those who did receive pay did so because of a patchwork quilt of arrangements that weren’t transparent, weren’t equitable, and had huge holes.” Although hospital-based faculty members are expected to spend a certain amount of time teaching, some refuse to do so, forcing others to take up the slack.

So, with changes slated to improve the curriculum, the School also decided to cast a critical eye on how it rewarded its faculty. This resulted in a plan to transform the Incredible Shrinking Teacher—the teacher–physician whose pay and prestige are often only slivers of those awarded peers in clinical care—into an appreciated, well-compensated one. It is a shift that could determine how the new curriculum fares.

“Faculty improvement is inexorably linked with the success of this curriculum,” says Thibault, which helps explain why Joseph Martin negotiated an agreement between the School and its affiliated teaching hospitals to increase substantially the level of compensation for doctors who teach. In addition, a new faculty promotion sys vtem is being implemented, aimed at giving faculty more credit for teaching and pedagogical scholarship. And letters of commendation are being sent to teachers who scored the highest in student evaluations.

For those teachers whose evaluations attest to a less than stellar performance, notices will be sent offering remedial help through the new Academy Center for Teaching and Learning. Such coaching will be required once the School has sufficient staff to provide it.

Valuable Perspective

Faculty members who excel at teaching will play a significant role in the Principal Clinical Experience (PCE), a revamped clerkship tailored to the cultures of the various teaching hospitals. Student volunteers have road-tested pilot versions at several Harvard-affiliated institutions—Cambridge Hospital, Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, and Massachusetts General Hospital.

Aside from the earlier May start, the key difference from the old clerkships is that the PCEs place students in one hospital for the entire year as they study all the specialties. This gives students a longitudinal experience, allowing them to work with the same patients and to witness those patients’ illnesses in various stages. It also provides the opportunity to work with the same faculty members for a year, portending improvements in everything from faculty mentoring to student assessments.

Beginning in the spring of 2008, all students will undertake a PCE. If the responses to the pilot programs are any indication, the new PCE concept will be a hit: In 2006, a majority of the third-year class, 107 students, volunteered for 68 slots.

And their enthusiasm is not misplaced. A recent study found that students undertaking the first PCE—at Cambridge Hospital—did at least as well, if not better, on Harvard and national board measures of knowledge and skills. Perhaps more notably, compared to their peers in traditional clerkships, students in integrated clerkships reported more confidence in their clinical skills, more satisfaction with their experiences, a better ability to integrate basic science and clinical medicine, a better appreciation of their own strengths and weaknesses, a better understanding of how social context affects patients, and less of the degradation of idealism that occurs typically during the clerkship year.

Changing the Subject

HMS is mindful of the greater impact of its curriculum reform. Dienstag recently attended a conference for medical education deans from peer medical schools as well as for leaders from several premedical programs. The deans talked of curriculum reforms at their institutions; the latter, how they were improving the teaching of science courses to students interested in medical school. “As a group,” says Dienstag, “we plan to recommend changes in premedical requirements to meet the needs of twenty-first–century medical schools and medicine.”

The group members agreed that undergraduate schools must place a greater emphasis on multidisciplinary courses that focus on more biologically relevant teaching of the sciences that underlie medicine. “Students are exposed to a great deal of material that is irrelevant in their preparation for the study of medicine,” says Dienstag. “Take general chemistry and organic chemistry, for example. Premedical students spend a lot of time on these subjects, but a substantial proportion of the material is not relevant to the study of biology or medicine. What is needed is a continuum of general chemistry and organic chemistry that prepares students for concepts in biochemistry.” If students are better prepared in biochemistry before entering medical school, he adds, then the medical school faculty can spend less time and effort on remediation, begin on a higher plateau, and bring students to a higher level of understanding and sophistication.

Dienstag notes a reality that outside observers readily concede: Harvard’s cachet means its reforms will be scrutinized and possibly emulated by other medical schools. “We have a grave responsibility not to make too many mistakes,” he says. “Fortunately, our standards are high; this is a very introspective place that’s never satisfied.”

Rich Barlow is a freelance writer who lives in Cambridge, Massachusetts.

Photo: uppercut images/getty images