Confronting a demanding and uncertain future for health care professionals, the School of Medicine is preparing for whole-scale revisions to all four years of its curriculum, scheduled for implementation in fall 2004.
The Curriculum Committee--made up of a broad coalition of faculty members and medical students--are leading the changes to an institution already unique among medical schools. Although the final structure is not complete, the past year's planning has fleshed out many of the details of the revision--the School of Medicine's first since 1966.
"As medicine and society change, the way we educate physicians must change," said Dr. Edward Halperin, vice dean within the School of Medicine and vice chancellor of academic affairs within the Medical Center. "Our mission is to adjust to the times while being mindful and respectful of eternal verities."
Students at Duke currently learn basic science in the first year alone--compared with two at other schools--and clinical science in the second year in the form of rotations. This leaves open Duke's vaunted third year for independent research and the fourth year for clinical electives.
Among the likely changes, subject material from the first and second years will be blended and taught in a more integrated manner; an organized curriculum complete with small-group discussions will be added to the second year; and more structure and required material will be added to the third and fourth years. The overall structure will remain intact, including the unique third year when many students pursue secondary degrees.
"The amount of time devoted [to each subject] will stay relatively the same. Where it occurs will start to vary," said Dr. Edward Buckley, associate dean of curriculum development. "In the first year there could be a fair amount of clinical exposure that's relevant to the material being taught and appropriate for the training level of the student. Likewise, in the second year, there's nothing that says you can't introduce scientific material."
Administrators list several reasons for reforming the curriculum: the increased complexity of medical concepts and technologies, a changing health care market with greater emphasis on preventive care, a national clinical skills test required of all medical school graduates beginning in 2005 and more focus being placed on the professionalism and communication skills of doctors.
"You have to adapt physicians to the way you think the future is going to be, and the future is not going to be unless you adapt physicians to help create it," said Dr. Ralph Snyderman, CEO of Duke University Health Systems.
To meet these goals, a major focus of the curriculum revision is changing the style of instruction, moving to greater utilization of technology and more labs and small-group discussions.
The plan calls for the first year to be condensed into three large courses--Molecules and Cells, Normal Body, and Body and Disease--covering the same breadth of material, but thoroughly altering teaching methodology and consistently working in clinical applications.
"[The first year] will become more of an interdisciplinary, not departmentally-owned endeavor-learning as it makes more sense," Buckley said.
Basic science in the first year is now taught from 12 lecture courses--roughly divided in subject matter by department and ranging from biochemistry to neurobiology.
"One of the overall curriculum goals is to increase the student-perceived relevance of the subject matter," said Dr. Emil Petrusa, associate dean of curriculum assessment. When learning about carbohydrates in biochemistry, for example, students could learn why diabetics are not able process the chemical and how it affects them, he added.
Petrusa added that some depth in basic science material may be sacrificed. "The basic scientists see it as a loss. The clinical people will see it as a gain and an improvement to clinical care," he said.
Organ systems form a unifying theme for much of the first year's later material. Students will likely learn several subjects--like physiology, anatomy and cell biology--surrounding a specific organ system, such as the heart, at the same time, instead of learning about disease at one time and the drugs to treat them at another.
"When you're practicing medicine, you don't think about how the drug you want to give [patients] fits into the scheme of pharmacology. You think about how it affects the heart," said Karen Joynt, a third-year medical student on the Curriculum Committee. "It's a smoother intellectual transition."
Jo Wright, vice dean of basic sciences, also lent support for the new philosophy. "I am a strong supporter of an integrated curriculum," she said. "I think it's important to change things to keep people vital and keep the curriculum active."
The second year is mainly composed of five required clinical rotations, in which students gain their first exposure to patient care. How clinical material is taught across the country has not changed significantly since the 1930s, but Duke is planning some innovation.
"Medical schools have not had a curriculum for the clinical work," Petrusa said. "The patient-contact experience has been random." For the first time, the revisions will add an organized curriculum to the clinical experience, he added.
In addition to following students more closely, the plans will likely institute a one-week inter-term between clinical rotations, consisting of small-group discussions on both their experiences and national health care topics.
The presence of departmentally-divided clinical courses will probably not change, however. "One of the neatest parts of the second year is being part of a team. Merging courses would pull you out of that," Joynt said.
Requirement of a thesis and other tracking methods have already been phased in to the third year, but administrators expressed hesitance about changing the year in other directions due to its centrality to the School of Medicine's identity.
In order to better bridge the gap between medical student and resident, curriculum revision to the fourth year may require a subinternship and some experience in emergency medicine.
Halperin pointed to the constant need for improvement. "The undergraduate medical curriculum is an organic structure, not static," he said. "Professors, students and administrators will, I am sure, embrace the excitement of innovation."
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