Revising the Medical School's Curriculum: A Full Text of the Report to the Faculty

The entire text of the report on the Medical School's curriculum is printed below. Several sentences referring to a schematic diagram (not reproduced here) have been deleted. Also, an appendix to the report has not been reprinted.--Ed.

In a time of great social upheaval and rapid developments in science no profession with its roots in science and its goal to serve society can remain unaffected by the changes taking place about it. Medicine today is such a profession. There has perhaps been no period in its long history when the demands and expectations on Medicine have been so great. The demands arise from the rapid increase in the world's population, the increasing affluence of modern industrialized society with its ability to pay for better than minimal health standards and the expectation that Medicine can reduce suffering, conquer disease and assure to all a better life free of physical and mental illness.

These demands and expectations have created new and diverse roles for the Doctor of Medicine. Proficiency in entirely new areas of health protection, e.g., rediation safety, environmental pollution prevention, population control, etc., is expected while traditional patterns of medical care are severely challenged. To survive, Medicine must evolve new patterns to deepen its roots in science and broaden its scope of service to society. Natural selection is too slow a process to insure survival; careful planning must proceed on several fronts. A clear view of the many new roles expected of the physician should lead to an education which will prepare him for the diversity of services expected of him. This view must lead to a reconsideration of the curriculum in medical school and proceed with bold innovations in both premedical and postgraduate education.

The aims of a new curriculum should be:

1. To allow more flexibility to meet the various needs of individual students that arise from differences in background, interests and choice of future careers in medicine.

2. To cultivate habits of independent thinking and scholarship which will insure continuing assimilation of new knowledge after graduation.

To accomplish these aims it seems necessary to:

1. Reduce the amount of factual information and memorizing pressed upon the students, and to allow more time for students to read, discuss and think in the atmosphere of a graduate school, rather than of a trade school.

2. Teach a "core curriculum" In a limited time by a coordinated interdepartmental activity.

3. Increase time in all years for elective courses designed to explore subjects in depth and taught primarily on a departmental basis.

4. Intermingle biological, behavioral and clinical sciences throughout the curriculum so that the student acquires a real sense of how the third draws its strength from the first two.

5. Maintain the motivation of most beginning students to help suffering humanity by introducing them early in their training to patients. This should be done in exercises designed to increase students' awareness of the emotional and socio-economic aspects of the preclinical sciences to pathophysiology of disease. An increasing responsibility for the care of patients, as rapidly as background and clinical skills permit, should also be provided.

The Core Curriculum

It is recognized that some core curriculum should provide the common information in the biological, behavioral and clinical sciences expected of all Doctors of Medicine. Because of differences in aptitudes and in training prior to medical school, parallel pathways may be required through part of this core curriculum. It is thought that this core could be taught by coordinated inter-departmental teaching which would serve to arouse the students' interest and excitement in the many fascinating areas of Medicine. It would not be aimed at didactic coverage of everything. Topics of great interest and pertinence may rather be emphasized with the thinking made clear, but with enough of the unsettled issues and unresolved problems introduced to stimulate the students to read, discuss, seek answers, design and perform experiments--in other words, to promote those highly individualistic exercises--usually away from the classroom--which for each student constitute the real educational experience. The core curriculum would also stimulate students to seek elective courses which would complement in depth the topics emphasized in the core curriculum.

Only by making the core curriculum a coordinated teaching exercise under continuous surveillance and revision by an appropriate body of the faculty do we think that the focus of the teaching can be kept on topics pertinent to the training of physicians. Only in this way, in turn, do we think that we can avoid undue cluttering of the curriculum with factual details. It is not our intent to belittle facts; the biological sciences unfortunately have not yet achieved broad generalizing concepts which reduce have not yet achieved broad generalizing concepts which reduce the need to know facts. We make this statement, however, in full awareness that it is not possible for every medical student to take from each course the detailed information expected of a Ph.D. candidate in that subject. However, he must acquire sufficient background and familiarity with each field to know when and how to return for further details when these may be helpful to him in his future work. To teach the details before the motivation to lean them exists, is pedagogy doomed to failure. We do not intend our remarks to lead to less rigorous teaching in the core curriculum but we do mean to say that major topics should be stressed and, to avoid undue repetition, considered from the vantage point of several departments so that the student feels the impact of this knowledge on Medicine in its broadest sense.

The stimulation the student receives in glimpsing broader fields and interrelations will undoubtedly bring him more eagerly back to those departments with approaches and knowledge which seem most likely to provide answers or extend insight. In the elective courses all, or nearly all, departmentally taught, the zeal of departments for teaching in their own disciplines may be unbridled upon a voluntary, no longer captive audience. In this setting depth and detail will quickly be learned.

The value of the whole-class lecture as a didactic technique is recognized. It is hoped, however, that more limited use of this technique will afford time for small group discussions and problem solving exercises in which the stimulus for learning may be more intense and individual needs more readily met.

The Councils

In order to facilitate the coordinated interdepartmental teaching and to provide proper balance, it is recommended that three Faculty Councils should be established:

1. BIOLOGICAL SCIENCES

Biochemistry

Microbiology

Biophysics

Physiology

Anatomy-histology-embryology

Pharmacology

Pathology

Genetics

2. BEHAVIORAL AND SOCIAL SCIENCES

Psychology

Sociology

Anthropology

Medical economics

Psychiatry

Preventive medicine

3. CLINICAL SCIENCES

Pediatrics

Medicine

Surgery

Neurology

Neurosurgery

Dermatology

Obstetrics-gynecology

Orthopedics

Urology

Pathology

Psychiatry

Clinical pharmacology

Radiology

Ophthalmology

Otolaryngology

Pathology teaching will be included largely in the Preclinical Sciences Council but representation on the Clinical Science Council is warranted for the clinical service functions it provides. Similarly, Psychiatry and Preventive Medicine will be based mainly in the Behavioral and Social Sciences Council but their clinical role will be represented on the Clinical Sciences Council.

It is intended that the several new disciplines included inthe Behavioral and Social Sciences Council be established as independent departments in the Medical School. Only from such a base, it is thought, can the quality of faculty that is desired and traditional be recruited.

Each Council would be responsible for planning an integrated course for a student within the time allotted to the Council. The Council would be encouraged to set up alternative parallel courses where important difference in background and aptitude exist.

Examples of topics in which each Council might provide an integrated course are:

1. BIOLOGICAL SCIENCES

Genetic coding and information transfer

Biological energy conversions Structure and function of cells and their organelles Contraction Membrance Phenomena Drug action

2. BEHAVIORAL-SOCIAL SCIENCES

Medical economics

Population control

Epidemiology

Legal Medicine

Biostatistics

History of medicine

Growth and development

Psychopathology

Computer science

Marriage and family counselling

3. CLINICAL SCIENCE

Physical diagonosis and case taking Introduction to the clinic Major clinical experience (In-hospital and ambulatory)

Specialty electives--all clinical departments

In addition to these intra-Council teaching exercises some inter-Council teaching will occur, as in Pathophysiology, requiring cooperation of the Biological Sciences Council and the Clinical Sciences Council, as well as in a community and family medicine project which should be a combined activity of the Behavioral and Social Science Council and the Clinical Science Council.

Plans for a Curriculum

There are many ways in which the integrated core curriculum may be combined with the departmental elective courses. The two kinds of teaching may run a parallel course throughout each academic year, e.g., core curriculum in mornings and electives distributed over afternoons. The core could be included within the first two or three years and the last one to one and a half years could be reserved entirely for elective courses. The core could be taught in blocks reserved for electives. One example of this last arrangement, which has the attractive feature that electives in all years are taught at the same time and thus potentially available to all classes, divides the academic year into three 15-week of vacation. The middle 15-week of vacation. The middle 15-week period of each year would constitute the elective period. A variant of this arrangement would permit this trimester system to overlap with the second semester at other graduate schools so that medical students could seek electives in the university and electives at the medical school would be available to other students. By making the three periods 20, 15 and 10 weeks, respectively, this can be accomplished.

Although it is not the intent or purpose of this initial report to spell out the details of a curriculum, it did seem advisable to map out the broad outlines of a program that we think would be workable. Undoubtedly other specific arrangements might serve the purpose equally well. [Our proposal can be summarized as follows]:

1. In the first year a coordinated course on cell and organ biology, taught primarily by the Biological Sciences Council, would constitute the major experience. This would be supplemented by Clinics designed to indicate the Importance of cell biology to clinical medicine. The students will make their first contacts with patients through instruction in interviewing.

2. The second year will be devoted to the major course in human biology. This will be a coordinated teaching exercise, conducted by the Biological Sciences and the Clinical Sciences. Blocks of time will be devoted to the major organ systems and normal function and structure will be presented as well as the abnormal. This will be supplemented by instruction in the Behavioral and Social Sciences and in the Clinical Sciences. The latter will now constitute case-taking with exphasis on the skills of history-taking, and the physical examination.

3. The third year will be devoted mainly to the Major Clinical Experience. This will be taught on the wards and in the clinics of the hospitals. It will be taught with emphasis on the whole patient rather than the approach of the specialist. Seminars presented by the Biological Sciences. The Behavioral and Social Sciences will provide instruction throughout the year, hopefully at the hospitals.

4. The fourth year will be devoted to elective courses offered in all divisions, taught by departments and chosen by students according to their interests and needs from a catalog with the help of their faculty advisors. Throughout the preceding three years, at least one-third of the teaching time will also be devoted to elective courses.

The role of the elective courses will be quite different from what it is currently. They will now become an integral part of the curriculum. They will provide at one time both the experience in depth required for attainment of scholarly attitudes and simultaneously give the desired flexibility to the curriculum. There would be three kinds of offerings in the electives:

a. Subjects not otherwise considered in the core curriculum.

b. Subjects considered in the core curriculum but now offered in greater depth and detail.

c. Opportunities for supervised but independent research.

There may be established some pre-requisites for certain of the electives. Thus it would seem reasonable that electives open to the first year class would be available to all upper classmen but the reverse situation need not apply.

The Electives

Students would pick their elective subjects from a catalog with the assistance of faculty advisors who will oversee the general program for each student and assure that balance consistent with the aims of the students is preserved. It is anticipated that most students will attain the M.D. degree having concentrated in clinical areas but it will also be possible to specialize in clinical areas such as medical genetics, medical anthropology, administrative medicine and so forth. It is considered that one elective for the fourth year might be an internship in an approved teaching hospital for selected students.

It is thought that this admixture of required core curriculum and electives will allow all students to be nourished by that material which should be common to all recipients of the degree of Doctor of Medicine and still allow flexibility to accommodate different backgrounds, aptitudes and goals. Essential opportunities to explore in depth will also be provided.

The advantages accruing to the faculty from this admixture of required core curriculum and electives should also not be overlooked. It is hoped that this mixture will provide more than a safety valve for those members of a distinguished faculty who may suffer frustrations by their participation in a coordinated program of teaching. These same faculty willhave complete freedom of action and expression in the elective offerings they provide. Opportunity for scholarship and distinction in teaching will be fostered with the likelihood that more great teachers will develop in this system. Our present block and coordinated teaching is so geared to an accepted urgency to teach everything to every student that it permits little opportunity for development by the faculty of presentations with distinctive personality and philosophy. An occasional lecture here, seminar there, does not engender the kind of teaching experience which brings the students to sit at the feet of the scholar, nor does it stimulate the teacher to mull over, reconsider his facts and premises, view his special area from all sides and interrelate his cherished intellectual offspring with other currents of contemporary thinking. In short, our present system does not provide those features which can make teaching the greatest of all educational experiences for the teacher. In the