Future Physicians Learn How to Learn

Editor's Note: This is the first in a two-part series examining the New Pathway curriculum at Harvard Medical School.

In 1987, Harvard Medical School made a dramatic shift away from the traditional medical curriculum in an attempt to prepare doctors for the complex world of 21st century medicine.

Rather than forcing students to memorize large quantities of medical facts and spend hours each day in lecture, the "New Pathway" emphasizes problem-oriented learning, small group discussions, increased emphasis on patient-physician relationships and self-directed study.

Harvard administrators have hailed the program as an innovative approach that would truly teach future physicians how to treat patients.

At the time of the curriculum's inception, some critics wondered whether New Pathway students would gain a solid enough grounding in the basic sciences to become competent doctors. Others questioned whether the program's emphasis on small-group interactions between faculty and students would be transferable to schools without Harvard's financial resources.

This year, the class of 1991, the first entire class to go through the New Pathway curriculum, graduates, and the report cards on the program are coming in. So far, most bear favorable marks.

New Pathway Philosophy

The New Pathway is based on the philosophical premise that it is no longer possible for anyone to commit the entire body of medical knowledge to memory. Instead, the program takes a liberal arts-oriented approach to medicine by teaching students how to think critically.

Myra B. Ramos, associate dean for educational planning at the Med school, says the program was increase in the rate of medical knowledge. It was becoming increasingly difficult to memorize all the information necessary."

"We wanted students to learn how to learn and how and where to find the knowledge needed, as the responsibility for learning to students, they become very active in the learning process, rather than passive recipients."

Elizabeth Armstrong, director of curriculum development at the Medical School, says that New Pathway will continue to pay dividends for doctors long after they leave Harvard. "We've accomphshed establishing patterns of lifetime learning," she says.

As part of the program, each medical school class of around 170 students is assigned to one of five "societies," which have advising roles similar to that of the undergraduate houses.

In 1985, the program began on an experimental basis when 24 students participated in the Holmes Society. The following year, 40 students took part in the same society, and in 1987 the entire school became part of the New Pathway with the creation of Cannon, Castle and Peabody societies.

In addition, students could join the already existent Harvard-MIT program in Health Sciences and Technology, which includes M.D./Ph.D. candidates.

Small Group Tutorials

A central part of the New Pathway curriculum is the tutorial, in which students have a chance to delve into a wide range of case studies and discuss them in a small-group format under the guidance of a faculty member.

Tutorials are a key element of a student's schedule. In their first two years, students participate in a tutorial and lab on alternate days, in addition to lectures, electives and a weekly "patient/doctor" class. The patient/doctor courses introduce students to patient-physician relationships and clinical medicine.

The third and fourth years are divided into clerkships that include rotations at the school's hospitals, as well as lectures, tutorials and more patient/doctor courses.

These third and fourth-year curricula are the most recently established parts of the New Pathway, and administrators say specific details are still undergoing revision.

LuAnn Wilkerson, the director of faculty development at the Med School, says the societies and their small group tutorials encourage students to think creatively about medical problems.

"Simulation is a powerful way for them to get to trust the method. They encourage students to see cases and how they fit into the full course structure," she says.

Wilkerson says that faculty members who have led tutorials have chosen to do so again. "The reason they come back is that they really enjoy working with new knowledge, skills and colleagues."

"There is a stronger faculty commitment with more teaching. That's energizing," says Armstrong, both faculty and students."

Tutorial leaders say their role is only to guide the discussion and make available their expertise in the field.

Assistant Professor of Medicine Steven L. Rabinowe, who leads an endocrinology tutorial, says that tutors act as "curbstones" in discussions to keep students thinking between correct lines. "Students generate their own discussion. We are also here to correct mistaken assumptions," he says.

Many times, Rabinowe says, current questions about a given case are asked, and the tutors, often experts in their fields, can answer them based on recent material that might not have appeared in textbooks.

"Students are more involved in the learning process. They think about the questions. There are plusses over memorization. You learn it better," he says. However, "it depends on student participation. Sometimes one or two students dominate a tutorial. The dynamics of the group are important. Our job is also to try to draw out quieter students."

Concerns Raised

Ramos acknowledges that serious concerns were raised, especially in its early stages, about New Pathway's ability to teach students essential medical knowledge.

She says that results of the Medical Board exams, which students nationwide must take after completing their second and fourth years, have been excellent, alleviating these fears.

And Armstrong says, "Questions on part one [of the Medical Board Examinations] have put basic science issues into a clinical context. They are more in keeping with our method in that they are more posed in a clinical context."

She adds that studies performed on the scores of students in the New Pathway have not been published yet, but that "the level of preparation should not be different."

Early on, some faculty members feared that the program would require an inordinate number of professors and that tutors would have to spend too much time in the classroom, Armstrong says. In response to these problems, Medical School Dean Daniel C. Tosteson '44 promised a "clinician educator track," she says, which would reward professors who choose to invest large amounts of time teaching.

Students Enthusiastic

Students in the New Pathway say that overall, the program prepares them well for future medical careers, although the approach may not be ideal for everyone.

"In general, students like [the New Pathway]. You have to be more prepared and more consistent," says Student Council Chair Rushika J. Fernandopulle '89. "Personally, it's the only way for me to learn medicine. It makes sense. I love it."

He cites the pass-fail grading of all classes as a benefit of the system, but says that students still prepare because the small tutorials make evasion difficult. The reliance on essays rather than multiple choice testing is also a positive asset, he says.

However, Fernandopulle adds, "I don't think it's for everyone. A lot depends on the educational mission of the school."

Paul W. Winterton, a second year medical student, says, "the emphasis on self-studying is helpful for the future." And students preparing for the boards can learn in review courses the basic science that the New Pathway does not stress. "The tutorials are better than just basics."

"I don't really have any criticisms, as long as the program is in continuous evolution," he says.

Nationwide Response

While most members of the Harvard community have reacted favorably to the New Pathway, educators at other institutions are not as quick to praise what they say is Harvard's not-so-new pathway.

"The program makes eminent sense," says Emilie H.S. Osborn '69, associate dean for student and academic affairs at the University of California at San Diego Medical School. "The problem is that all of the New Pathway is not quite new. Most medical schools have cut back on lecture learning." For example, she says the University of New Mexico employs more community-oriented learning.

"We have a lot of small group learning. [Harvard's initiation of the system] has made it mainstream. Their program is not more radical," Osborn says. "What I've seen is that there's quite a lot of getting away from teacher-driven education."

Administrators at Columbia University's College of Physicians and Surgeons in New York say they are interested in the curriculum, but are not sure that their school will adopt it.

"We don't think that we'll end up with that kind of curriculum," says Curriculum Coordinator Flora Atkins. "Everyone is extremely interested, and there is probably a small group which feels it is the way to go."

Atkins says the problem is a lack of space at Columbia for such a program. "We don't have the facilities," she says. She also says that the program is "much too faculty intensive."

Atkins says of her own school's program, "We have some terrible failings. There is not enough problem solving." Other several changes to the basic sciences sequence, Columbia's curriculum has not changed in 20 years, she says.

"We have a very traditional curriculum. Students come here for that, and do well," Atkins says.

But regardless of whether other medical schools implement a program similar to the New Pathway, it has attracted attention from physicians across the country. Atkins says five administrators from Columbia visited Harvard to see the program in action.

"Everyone is talking about [the New Pathway] at AAMC [Association of American Medical Colleges] meetings," she says. "The influence that Harvard has had in doing this has been great."

Friday: A look at a Public Television series that is following seven medical students over a ten-year period to examine the effectiveness of the New Pathway program.