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The Pulse of a New Medical Curriculum

When he found out he would spend his third year of medical school based at Brigham and Women’s Hospital, rather than rotating among hospital venues every few months, Babak Nazer knew he’d gain from having an ongoing group of physician mentors at the Harvard-affiliated institution. What he didn’t expect was the benefit of being comfortable in the place itself. “Walking down the halls and recognizing people makes you feel like you’re home, like you belong somewhere,” he says. “I felt a little more free to learn the material and delve into patient care, instead of trying to figure out how to find conference rooms, traverse the computer system, or order certain radiology exams.”

Nazer, a 24-year-old from Seattle, was one of a dozen Harvard Medical School (HMS) students who undertook experimental clerkships at Brigham and Women’s during the 2005-06 academic year. They were part of a trial run for a curriculum revision aimed at preparing them to become effective physicians amid the major changes of twenty-first-century healthcare delivery.

“Integration” is the theme of the process, which launches officially this fall. From classrooms to clinics, work is under way to better connect the basic-science and patient-care aspects of learning; ensure that courses build on each other logically; strengthen ties among faculty, students, and teaching hospitals; and weave social issues like health policy and ethics into the curriculum. The key planned outcomes are to design a four-year, longitudinal curriculum and re-engage physicians in teaching. “The faculty have been talking with one another and thinking about ways to teach better and more efficiently,” says HMS dean for medical education Jules Dienstag, a longtime faculty member who assumed his present post in May 2005. “We’re really focused on providing the best educational experience for our students.”

Babak Nazer (left) and Leonard S. Lilly
Photograph by Stu Rosner

Doing so has become ever more challenging of late. Shorter hospital stays often mean students have only “snapshots” of time with patients. Mounting paperwork, incentives to conduct world-class research, and financial pressures to turn patients around quickly have sapped doctors’ teaching time. New technology, drugs, and other discoveries need to be folded into the curriculum. The Association of American Medical Colleges frames it this way: “Medical students confront developments that their predecessors never imagined—from managed care and a multicultural society, to palmtop computers and medical informatics, to the genetic code and harsh realities of public health that include domestic violence, homelessness, and AIDS, to learning new ways to enhance healthcare quality while minimizing medical mistakes.”

Change at a research university of Harvard’s scope and tradition rarely happens quickly. The medical school has tweaked its curricular offerings before, but this is the first major restructuring since the New Pathway program in the mid 1980s began emphasizing small-group “tutorial” instruction and problem-solving during the first two (classroom) years. This latest effort, the school’s Medical Education Reform Initiative, aims to incorporate New Pathway’s active learning approach into the clinical (patient-care) years—noeasy matter in the current context of efficiency-oriented hospital operations.

The process began in earnest in 2001-02 and has involved 300 to 400 of the roughly 10,000 HMS faculty members (most of whom are practicing physicians or researchers with appointments in the affiliated hospitals), as well as administrators, students, and hospital leaders serving on multiple committees and task forces. Progress reports were shared with the school community, and in December 2005, the project’s leaders approved a structure and time frame for the new curriculum, which they agreed to roll out in phases.

What’s different at HMS this academic year are an “Introduction to the Profession” for entering students (see “Doctoring 101”), a more “holistic” approach to classroom learning during the first two years, and an expanded set of pilot clerkships for third-year students, such as Babak Nazer’s. Committees are still at work, Dienstag notes, to refine the fourth-year experience, embed in-depth scholarly projects in the curriculum, and augment faculty rewards for stellar teaching.

A year in the life of a third-year student

Although based at Brigham and Women’s Hospital (BWH, in Boston’s Longwood Medical Area) for his pilot clerkship this past year, third-year student Babak Nazer was able to sample several other area institutions as part of his clinical experience:

  • 3 months of surgery at BWH
  • 6 weeks of pediatrics at Children’s Hospital Boston
  • 6 weeks of obstetrics/gynecology at BWH
  • 3 months of medicine at BWH, one of them at the Veterans Administration Boston Healthcare System’s West Roxbury campus; another month in outpatient clinics
  • 1 month of neurology at BWH
  • 1 month of radiology at Dana-Farber Cancer Institute/BWH
  • 1 month of psychiatry at BWH

To breathe new life into classrooms, HMS faculty leaders are adding, rearranging, or dissecting various “preclinical” courses. Students’ learning will typically advance from small to large in building-block fashion; for example, a revised course on cell biology and biochemistry will now precede the studyof anatomy, so that instruction will progress from molecules to cells to organisms. In addition, topics underscoring the social context of medicine—such as health policy, social medicine, clinical epidemiology, and medical ethics —are being elevated to required status (and their themes integrated into the teaching of the basic biological sciences), and a veteran course on doctor-patient communication is being revitalized. Certain ailments such as diabetes or HIV/AIDS will form an educational scaffold on which to teach across different disciplines.

The review has compelled course leaders to coordinate their efforts more than ever so that related subjects like genetics and ethics are taught in sync. Associate professor of medicine Richard Schwartzstein, M.D. ’79, who teaches physiology, is one of them. “The first number of years I taught the course, I did feel a bit like an island,” he told the school’s Web Weekly. “Now there’s much more sense of collective responsibility for the education of the students.”

Under the current system, third-year HMS students plunge into supervised patient care by doing one- to three-month rotations in affiliated healthcare centers, including large teaching hospitals such as Beth Israel Deaconess Medical Center, Brigham and Women’s, Children’s Hospital Boston, and Massachusetts General Hospital. They immerse themselves in one institution and discipline, such as surgery, pediatrics, or psychiatry, and then switch to the next, where they must establish relationships with a new cadre of faculty and patients.

That system worked well for years, observers say, but in today’s hospitals, students face a fragmented experience and little “dwell time” with residents, attending physicians, and patients. “When I was at medical school [at Columbia] decades ago,” Dienstag recalls, “students were the center of rounds. Attending physicians would go through the medical and basic science issues underlying a patient’s condition, leading us through a Socratic discussion. In the old days, a patient would be hospitalized for the evolution of her disease. A person came in with a heart attack and stayed 21 days, not a day less. Today, if you have an uncomplicated heart attack, you’re normally out the door before you have a chance to get comfortable.”

Inpatients’ acuity, or level of sickness, is higher now “as society has decided that patients are better cared for outside the hospital,” he adds. “Your attending physician has only two hours to ‘round’ with students and residents, see each patient, do a history and physical, and make sure the medical note is written and the patient’s discharge is arranged. So you have a relatively chaotic, high-acuity, rapid-turnover approach to medicine.”

In reviewing the existing clerkship system, HMS leaders decided students would benefit from concentrating on one hospital, where they would develop longer-term bonds with faculty and patients. They’d get to see patients in different settings, such as outpatient clinics connected to the hospital (see sidebar, below); meanwhile, small classes would supplement the direct-care work. During the past academic year, 28 of the 165 third-year students took part in pilot clerkships, and 68 are signed up for 2006-07 at Beth Israel-Deaconess, Brigham and Women’s, Mass. General, and Cambridge Hospitals. Another 40 students applied for this year’s program but landed traditional clerkships instead; the new approach should be open to all by spring 2008.

Rachel Bortnick, an M.D.-Ph.D. candidate from Bethesda, Maryland, spent last year based at Cambridge Hospital, a full-service community hospital near Harvard Square. Cambridge’s new clerkship differs from the others; instead of having students follow a sequence of disciplines, this group works throughout the hospital’s clinics and emergency room, picking up patients along the way to follow during the year. All teaching is done by attending physicians, and the direct-care work is supplemented by small-group learning focused on case discussions.

Bortnick followed roughly 90 patients, seeing some only once and some regularly. One woman came into the medicine clinic with a rare skin disease, “and I accompanied her to the infectious-disease specialist and dermatologist,” Bortnick recalls. “We looked at her biopsy specimen with the pathologist. During the year, I went with her to appointments and coordinated everything with her specialists. It was an incredible learning experience, and ideally, it improved her care.”

Bortnick believes the clerkship’s patient-centered approach works well for budding doctors. “We spend 99 percent of our time learning,” she noted this past spring, “because we’re always seeing patients, talking about our patients, reading about our patients, looking at our patients’ films. It just makes a lot of sense.”

Although “doctor” comes from the Latin word for “teacher,” not all physicians are effective teachers. To help faculty members sharpen their pedagogical skills, both in the classroom and at the bedside, HMS launched the Academy Center for Teaching and Learning in March 2006. “Part of our mission is to think about faculty development as integral to the flourishing of the new curriculum,” says director Charles Hatem, the Amos Academy professor of medicine. The center-in-progress will use faculty interviews and surveys as part of a needs assessment for developing appropriate programs, such as training in the art of lecturing. Good teachers, Hatem says, display passion and curiosity for the field and care about their students. In medical school, faculty members provide feedback and guidance essential to the professional development of these future doctors, especially as they are choosing among medical specialties.

One of Babak Nazer’s standout mentors was cardiologist and associate professor of medicine Leonard S. Lilly. During his month-long outpatient-medicine rotation, Nazer saw patients with Lilly at the Brigham and Women’s/Faulkner Hospitals campus on Mondays, and reviewed echocardiograms (heart tests using sound waves) with him at BWH on Fridays. “He’s like my hero,” Nazer says. “I admire the way he interacts with his patients. He always remembers details about their lives, and I’m struck by how meticulous and thorough he is with their care. Dr. Lilly is also an amazing teacher; he doesn’t race through patients, and he schedules them far enough apart so he can teach me in between.”

Lilly choreographs his schedule in order to make valuable matches between patients and students. Tomorrow’s doctors, he maintains, need to learn about cutting-edge medical technology, but not at the expense of the basics—how disease happens. “It’s also important that students understand how to ask patients the right questions and examine them to get the right information at the bedside,” he says. “If we end up with a generation of students and young physicians who don’t know how to do a proper examination, who’s going to teach the next generation?”        

    ~Debra Bradley Ruder