The New Curriculum
Medical student education in the twenty-first century
Gordon Churchward, Associate Professor of Microbiology and Immunology; Chair, Foundations of Medicine Steering Committee


Vol. 10 No. 2
October/November 2007

Return to Contents


Measuring Up
Quantifying the quality of an Emory education

Selected Results from the National Survey of Student Engagement

“Our goals are so complex that learning outcomes assessment will measure only a small part of what takes place while our students are with us.”

“I think it’s important for students to know a lot of facts [and] figures. . . . If you haven’t acquired that basic, empirical knowledge, the structure of reflection you build upon collapses.”


The New Curriculum
Medical student education in the twenty-first century


The Transforming Community Project

Practicing Diversity in the Academy
Uncovering and engaging Emory’s racial past and present

Uncovering the Past, Looking to the Future
Experiencing a community dialogue at Emory


Endnotes

Interview day. Another smartly turned-out youngster comes into the interview room. Her academic accomplishments are a given (we aren’t supposed to peek at the grades until after the interview). His personal statement (which, like all the others, is strangely unrevealing) catalogues an impressive record of accomplishments in community service, sometimes local, sometimes international. But as the interview proceeds, we nearly always get beyond this carefully constructed façade, and an image of the real person emerges—bright, engaged, compassionate, caring. Life-long passions are revealed—dance, literature, art. Keen interests are discussed—fantasy football, soccer, the contrasts between baseball and cricket. Moral dilemmas are exposed—how involved should I become in my sibling’s battle with addiction; how should I relate to the parent who walked out on the family. At the end of an hour (I often run late), I am thinking that this person could make the kind of physician that I would want to take care of me. At the end of the day, I have to rank the candidates according to a scale—talk about a Lake Wobegon effect. And the best will come to Emory School of Medicine.

How do we educate these extraordinary young people and help them develop their potential to become leaders in their chosen profession, while maintaining the very best of their personal characteristics that will enable them to be caring, ethical physicians who can empathize with their patients?

Medical education in the United States has, for the last hundred years, followed the plan laid out in the Flexner Report. (A non-technical account of Flexner and his impact on medicine in this country appears in John M. Barry’s description of the 1918 flu pandemic, The Great Influenza.) Medical schools are affiliated with institutions of higher learning. Medical school training consists of basic science education followed by clinical training. At each step along the way the students are monitored for basic competency by grueling examinations administered by the National Board of Medical Examiners (NBME). The educational activities of medical schools are closely monitored by their accrediting organization, the Liaison Committee on Medical Education (LCME).

Since the Flexner Report was published, the science underlying the practice of medicine has undergone a series of revolutions due to discoveries in physiology, biochemistry, molecular biology, and genetics. Our understanding of ourselves, from the organism level to the cell and molecular level, increases at an extraordinary rate. Yet the time available to impart this knowledge to our students has remained unchanged. The NBME examinations act as a curriculum straightjacket, reducing education to “Will it be on the test?” Our knowledge of the scientific basis of human disease, albeit incomplete, makes the division between scientific and clinical training obsolete. Social pressures shape the practice of medicine. How are physicians supposed to care for, as opposed to process, patients in an era of the fifteen-minute office visit? How will today’s students be trained to deal with the anticipated increase in demand for geriatric services?

Many schools have grappled with these kinds of issues. The LCME has promulgated standards intended to address some of them. In addition to their general standards, LCME insists on training in community health, end-of-life care, family violence, multicultural aspects of medical practice, nutrition, and preventive medicine. In addition, schools have changed the way they teach students. Organ system-based curricula, in which basic science content is integrated into discussions of pathology and pathophysiology affecting each of the major systems of the body, have become increasingly common. Some schools still rely heavily on didactic lectures, while others have moved to problem-based learning in small-group discussion formats.

Our approach has been to examine other schools’ responses and to reflect on how we can combine the best ideas with the extraordinary resources that exist at Emory to design a new curriculum that will serve as a model for the twenty-first century in the same way that Flexner’s ideas served as a model for the last century. Our goal is to create a learning environment that fosters creativity, sustains curiosity, and leaves abundant opportunity for our students to pursue their own interests. We want our students to learn their trade from our master clinicians. We want to emphasize clinical care throughout the curriculum. We want to escape the confines of a curriculum solely dictated by the NBME examinations. We want to break from the stultifying grind of endless lectures. Above all we want to foster an environment where the students are partners in their own education and we, as faculty, take on the role of guides rather than instructors drilling students for the test.

To accomplish these goals, the medical school’s Dean Tom Lawley set up a committee whose charge was to examine and make recommendations about all aspects of the education mission of the school. A plan evolved from these deliberations. The curriculum would consist of four phases. The first eighteen months, the Foundations phase, would begin by presenting a subject surprisingly much underrepresented in medical school curricula—human health and what it means to be healthy—followed by an integrated organ system-based presentation of human disease. Clinical training coordinated with curriculum content would begin in the third week and continue throughout the eighteen months. After a break for preparation, NBME examination, and recovery, the students would begin the second phase, the year-long Applications phase. This phase would include the major clinical rotations. Following the Applications phase, the students would enter the Discovery phase, in which every student would be expected to carry out a scholarly investigation in a field of particular interest to them. This might, depending upon the student, be extended to permit the student to follow a degree program in another discipline. Finally, the students would reassemble for the final Translation phase, in which they would undergo training to permit them to excel in their chosen
residencies. This would include a capstone summation of their medical training.

So what is new? First, in the Foundations phase, there is a large reduction in the number of lectures, compared with the current curriculum, and increased time available for faculty- and self-directed independent study. Second, we have instituted a system of faculty mentors so that small groups of students meet with a mentor twice a week for both instruction and mentoring. These groupings will continue throughout the students’ time at Emory. This system formalizes the student-mentor relationship, and it ensures that all our students have a mentor to guide them through the sometimes-turbulent currents of their training. Third, all students will be expected to engage in scholarly activity. Graduation from Emory will mean more than facility at preparing for the exam. Finally, training in the clinical years will include further advanced instruction in the relevant basic science, at a time when the students are better equipped to appreciate its significance.

So what are the problems? When asked about their efforts at curriculum reform, colleagues at other schools use phrases like “blood on the floor.” No blood has been spilled yet. It is understandably difficult for everyone to accept the need for extensive change when, by any objective measure, our current curriculum yields outstanding results. The NBME scores of our students are as good as any in the nation, and an astonishing fraction of our students gain their first choice of residencies. But we are a collegial faculty and, despite sometimes significant differences of opinion, I have yet to meet anyone who, when challenged, does not admit that we could do better by our outstanding students.

So what has been the effect of the reform? There has been a tremendous engagement on the part of both basic science and clinical faculty members. People who were not aware of one another’s existence a short while ago are talking. The teaching mission of the School of Medicine has been a given a new prominence. For me, one of the most impressive aspects of the reform has been the willingness of outstanding faculty to devote enormous amounts of time to make sure that we grasp this opportunity and make it a
tremendous success.

So are there other critical factors? There is one. The new School of Medicine building is open for business. We could not hope to succeed without this extraordinary new home. It has state-of-the-art facilities for student training using standardized patients (role playing actors). It has a complete operating theater and ICU recovery suite set up for simulation training and observation. It is the best facility for medical education in the country. And, architecturally, it is stunning.

So where are we? At the time of writing, the first-year class is about to begin its fifth week of the new curriculum. They have spent a week in orientation being jabbed and poked and doing all the online training required for them to set foot on a ward. They have spent a week shadowing health care teams in the hospitals and have discussed this experience with their mentors as their transition from patient to doctor begins. They have listened to a series of presentations from eminent Emory faculty about different aspects of health care and have begun to learn how to take a patient’s history and perform a physical examination. They have finished their first week of coursework and taken their first test. They have heard from their friends at other schools who have gone from being anxious and apprehensive to being more anxious and overwhelmed. They, on the other hand, seem relaxed and are enjoying themselves while getting down to the work of becoming a caring, ethically grounded physician. It looks like all the hard work is going to pay off.