Med School Curriculum Reform: Warming Up for a Lengthy Debate

"It's a really stultifying thing," a professor remarked last week, "for students to go to Harvard Medical School for four years. They can't make any decisions at all about what courses to take. We put the whole goddamned bunch through the same curriculum. And it just doesn't make sense."

Another professor gazed gloomily across his office at a pair of three-inch folders. "I look over there and see 14 pounds of notes for a single course," he shook his head, "and I say it's too much."

Things have been that way since 1910, when the Carnegie Foundation for the Advancement of Teaching issued a searing -- and much-publicized -- report indicating that this country's medical students rarely received systematic or competent instruction. Almost immediately, fly-by-night medical schools "collapsed to the right and left," Abraham Flexner, the report's author wrote later. Remaining schools dedicated themselves to teaching students all there was to know about medical science.

But each year there is a lot more medical knowledge. Conscientious professors try to teach as much as they can, and students write it all down and try to learn it. This year, a special faculty subcommittee has said the whole routine is dreary and out-moded. Its report recommends that the Med School give up teaching everybody everything and let students have the freedom to study what interests them.

It asks for the first major Med School curriculum change since the Flaxner report was released. It suggests cutting the workload, offering many new courses, and beginning small-group teaching on a large scale. For the first time, students could choose a number of courses for themselves.

But the New Medicine has aroused bitter criticism from some faculty members, and its future is not at all certain. Perhaps to stir any debate at all over the curriculum, Robert H. Ebert, dean of the Med School, apparently felt it necessary to skirt the standing faculty Committee on Curriculum and have a totally new group draw, up the report. He asked Dr. Alexander Leaf, a member of the Curriculum Committee, last year to pull together a subcommittee. Leaf's sub-committee produced its report last Spring. Rather than risk the Curriculum Committee's toning it down, Ebert threw the proposals to the entire faculty in September. The faculty has been officially debating them at its monthly meetings since then, with unofficial debate continuing through the Med School corridors and offices.

If the faculty can reach agreement on the suggested changes, further committee work on specifics shouldn't take long. But first the faculty must agree--and that will take some time. Key votes probably won't come before Spring.

Harsh critics of the 23-page report -- there is a significant number -- are wary of just about everything in it. The report sketches a whole new way for the faculty to operate, and professors uneasy about a complete curriculum overhaul call its objectives unrealistic and its plan of action unworkable. Some seem rather offended because the report makes such sweeping recommendations which many fellow faculty members seem to favor.

"They've gone overboard," sniffs one professor. "Faculty meetings have been sounding like the old Oxford Movement meetings, everyone sitting around and telling their sins," complains another. "Well, we haven't been turning out such disastrous students. They're the leaders of American medicine."

An element of tension has been injected into the debate by the unprecedented publicity the report has received. After the New York Times picked it up, at least one professional journal reprinted it and suggested that readers write away for copies. It's the first time in memory that a faculty debate at the Med School has not been a strictly private affair.

"It's like the story of the Japanese spy who was getting information from the English, and they knew it," growls one critic of the report. "So they fed him plans for a battleship that would sink, he duly copied it, it was built, and it sank."

But temperatures would run high even if the spotlight weren't on. There is a lot of tradition at the Med School, and the report implies that a good deal of it does more harm than good. The report strikes hard at a once highly respected tradition -- departmental autonomy.

Does Tradition Hurt?

The departments have long enjoyed the freedom to plan one course of their own and require every student to take it. The report suggests that required departmental courses, which now take up just about all of a med student's time, be eliminated. Subcommittee members say it is the key recommendation -- most critics of the report would no doubt agree.

The departments, explains a member of the subcommittee, have "a foie gras philosophy of teaching. We have the feeling that we're never going to see these students again. So you simply grab them by the necks and ram the food into them. They're like so many Strassford geese."

Under the report's recommendations, interdepartmental committees would scrutinize the material now offered in the required courses, hack out a lot of it, organize what's left into a logical sequence, and ask a large number of professors to lecture individually on a little bit. Departments would use time and manpower saved to offer a variety of electives.

The interdepartmental courses -- what the report calls the "core curriculum" -- would in effect form a sort of Gen Ed program for doctors. The core, the report says, would provide each student with "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."

Electives would be small courses, like graduate seminars, exploring minute areas in depth. A professor could teach anything he wanted in an elective, and could throw as much detail as he desired at his students -- if he still had any.

To critics, the prospect is chilling; to some, it is the most objectionable idea in the report. It strikes them as a time-consuming system to plan, and painful to participate in. Explains one, people from different departments "don't normally see each other," the meetings would be difficult to arrange, and once they were held, everyone would wrangle for hours trying to cram into the "core" as much of their own subject as possible. "If you talk to anyone in any department, agrees another professor, "they'll say their subject fits right into that irreducible minimum."

Some courses, including a couple of current ones, have from time to time been taught by members of more than one department. But a number of men obviously would chafe if they had to teach under the proposed system. "When you get a committee telling me that I give a lecture on this one day and on that another day, I feel like a $50-a-day call girl," rasps one. "There's nothing here that belongs to me but two lectures in a smorgas-bord that a committee has put together."

Critics agree that "core" courses just wouldn't be good, though they offer wildly different explanations. One professor predicts that teachers would have to leave out all of the new and exciting but irrelevant developments in their field. "If you just left in the things that every doctor should know," he worries, "it would be unpalatable. It would be like eating sawdust." Another professor, however, is sure that lecturers would drop the essential in favor of the new and exciting. "If we didn't attract students