This is the second installment in a three-part series on major changes in medical education. Tomorrow's story will focus on changes to graduate medical education at the University.
Recent and impending changes to the Medical School curriculum represent the most sweeping restructuring witnessed at the University since 1966.
The Medical School, like many others around the nation, has reevaluated its curriculum and programs in recognition of two main factors: first, a reconceptualization of "health" to include psychological and social well-being, and second, the market demand for more primary care physicians and cost containment.
"This is major," said Dr. Dan Blazer, dean of medical education. "This is probably the biggest change we've made in our curriculum in 30 years."
Back then, the University instituted the current "1+1+1+1" curriculum--one year of basic sciences instruction, one year of clinical rotations, one year of basic sciences research and one year of clinical electives.
To ensure that medical school graduates are prepared for the 21st century's managed-care environment, educators at the Medical School have ushered in a plethora of opportunities and requirements with an eye toward integrating the traditional biomedical curriculum with social issues in a community-oriented, ambulatory care setting.
Some of the new curriculum's defined goals include early exposure to patients and community-based private practices; continuity of experience with those patients and practitioners; and interdisciplinary care, said Linda Lee, an education specialist in the Office of Medical Education Research and Development.
The major changes include:
In the first two years of medical school, a longitudinal course--Progressive Responsibility and Care through Integrated Curricular Experience, or PRACTICE--that integrates health-care issues, interviewing and examining patients in an ambulatory setting, preventive care and health education. The course will be phased in with next year's incoming class.
In the second year, a two-week clinical clerkship in cost-consciousness.
In the second year, the voluntary pairing of medical students and physician assistants for eight weeks in a community-based practice.
In the third year, the option of getting a master's degree in public health at the University of North Carolina at Chapel Hill or participating in Duke's Epidemiology, Health Services, and Health Policy Studies Program in lieu of the basic research requirement.
In the fourth year, an increase in the number of primary and ambulatory care electives, including a new requirement this year that all students spend at least four weeks in an ambulatory patient setting.
The creation last year of a new assistant dean position dealing specifically with primary care.
A defined set of core competencies that each medical student is expected to achieve prior to graduation. One requirement is that each graduate "demonstrate the knowledge, skills, and decision forming processes necessary as a general physician."
Dr. Barbara Sheline, named assistant dean for primary care last year, directs the current first-year lecture on Fundamental Issues in Health Care, which will be replaced next year by PRACTICE. Unlike the current first-year course, PRACTICE integrates didactic instruction once a week and clinical ambulatory experience. Sheline was unavailable for comment.
While the basic sciences curriculum remains largely intact, the PRACTICE course ensures that every medical school graduate will have the requisite skills to perform in a community, ambulatory setting, skills that differ significantly from those required in a hospital inpatient setting. "The main criteria is that these people are seeing patients over time," Blazer said.
"The goal of this course, regardless of what type of physician the student happens to be, is that they're going to learn certain techniques and certain approaches to working with patients that are the basic techniques and approaches you would expect in a primary care physician," he said.
While this year's entering class is not being exposed to PRACTICE, Blazer said that most of the required clerkships second-year students participate in now have an ambulatory component.
In addition to being more exposed to primary care, students are now required in their second year to learn first-hand about the economic effects of physicians' medical decisions. The two-week clerkship in cost-consciousness, tested last year, will continue to combine didactic and hands-on experience. During the clerkship, small groups of students study in detail all aspects of real patients' cases. They also talk to patients and families, learn about their insurance coverage and go over their bills.
"They get a sense of who is paying for medical care and what is the cost of medical care and why does it seem to be so expensive and where do the costs really go; how much does the doctor get, how much goes for medications, how much goes for laboratory tests, etc.," Blazer said. "In the process of that, one thing that students often pick up, even these second-year students, is that probably a lot of things are done that don't need to be done."
Toward the end of the clerkship, students are required to assess one aspect of the system that does not seem to be cost-efficient, make recommendations and "try to estimate what types of cost-savings there might be," Blazer said. "We have actually been quite impressed with some of the ideas that our students have come up with." Blazer added that Hospital officials are examining the viability of implementing some students' papers.
The cost-effectiveness clerkship is probably a temporary addition. "We think in time we probably will be able to eliminate the cost-effective care course because we feel like this will be so much a part of the system and so much a part of the way all doctors are practicing that the students will pick this up naturally when they're on their regular clerkships," Blazer said.
Also in the second year, medical students are being introduced to the idea of interdisciplinary care, working with "physician extenders"--physician assistants (PAs) and nurse practitioners (NPs). In North Carolina--where half the population lives in rural areas--the problem of cost containment and inadequate access to health care may be partially solved by using PAs and NPs, who under the remote supervision of a physician, would provide health care to underserved rural areas.
One program, started last year with a grant from the Macy Foundation, pairs those medical students who choose to do an eight-week family medicine clinical rotation with physician assistants in a community-based practice. Lee said that each pair of students, while learning to work as a team, also does an assessment of a health-care problem in the community.
The third year of basic sciences research is now only one of several options Duke students have. For the first time this year, some are spending their third year studying at the University of North Carolina at Chapel Hill to earn a master's degree in public health. Others, preferring Duke Blue, are enrolling in the University's Epidemiology, Health Services, and Health Policy Studies Program. The program is in its third year.
"We felt that [for] people who were going into primary care, often their research interests would be in these areas," Blazer said. "It does provide them with skills that I think are more applicable to the kind of academic lives that maybe someone would have in a primary care setting than, for example, molecular biology or genetics."
Seth Kaplan, a fourth-year medical student pursuing general pediatrics, went through Duke's public health policy program. "Those of us who went through that program have a better understanding of where the health care system is going and how we're going to interact with that health care system in a broad sense," Kaplan said.
Although the Medical School has revised the curriculum and made more opportunities available, it is not altering its mission. "We probably don't need to do a whole lot in terms of pushing people toward primary care. In fact, we're not really sure that's really our goal," Blazer said.
"What we need to do is make certain that students who graduate from here and who have an interest in primary care are just as well trained and just as capable of going out and working in a primary care setting as students who go into a specialty area," he added.
Medical schools' traditional bias against primary care fields is also changing. "I think we have a responsibility to show students that a career in primary care is just as attractive and can be just as intellectually stimulating and rewarding as a career in one of the specialties," Blazer said.
Duke has been ahead of other medical schools in making the changes.
In the August issue of Academic Medicine, a study of five medical schools that teach an integrated approach to health care was examined. The article, which Linda Lee co-authored, states that, "many believe... that a focus exclusively on disease and its biomedical treatment cannot adequately address the broad range of contemporary health care problems, whose complex etiologies and management reflect many interconnected personal, social, and environmental influences on health and illness."
Each of the five schools Lee and her colleagues examined has an institutional mission that "generally has a service-oriented, patient-centered perspective." These schools weaved into their curricula an approach that addresses four relationships: physician-patient, physician-community, physician-other practitioners and faculty-student.
"An institution like Duke which is research focused... is not as fully integrated, because at other schools [integrated care] is part of their mission. Given Duke's mission, [the revised curriculum] is an excellent approach to dealing with the total patient picture," Lee said.
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