As the School of Medicine revamps its entire curriculum to make training more relevant to modern health care, the changes to the second year focus on preparing students for the actual experience of being a physician.
The revisions include the addition of three elective clerkship rotations for students to explore subspecialties of medicine and also incorporate more classroom time, some of which is devoted to clinical reasoning skills.
"These changes really give an opportunity for certain issues to be more thoroughly and continually addressed," said Colleen Grochowski, associate director of curriculum development, noting specifically that it allows topics such as geriatrics, ethics and insurance to enter the consciousness of students.
The most revolutionary alteration to the second year is the addition of five week-long intersessions between the clinical rotations that include basic science lectures, practice diagnostic exercises and experience with aspects of health care that do not include physicians, including physical rehabilitation and social work. The extra classroom time gives the School of Medicine a chance to teach topics that do not fit into the traditional course structure, such as nutrition, pain and palliative care.
The mini-terms focus directly on increasing independent learning and connecting both the clinical science learned on the wards and the basic science learned in the first year to clinical reasoning and problem solving.
"It's an opportunity for students to learn either skills or concepts that will really help them when they step out into the world," Grochowski said.
The changes to the second year directly address a mandate from the Liaison Committee on Medical Education in Nov. 2001 that Duke monitor students' progress more closely after the first year.
"For pieces of the curriculum, we needed to prove the students were really learning it," said Dr. Barbara Sheline, associate clinical professor of family medicine and one of the coordinators for the changes to the second year. "Often you send them out to the wards for eight weeks and no one's watching them."
With the new curriculum, faculty will see students in between rotations and thus be able to evaluate their progress more closely. The second year is traditionally composed of eight clinical rotations in which students spend time learning various disciplines of medicine--including surgery, family medicine, pediatrics and internal medicine--in a clinical setting. Currently, students never come back to the classroom as a whole class.
Bringing the students back in the middle of term also allows faculty to teach specific skills for working on the wards immediately before students need to know them. For example, before their internal medicine rotation, students will learn about electrocardiograms and how to read them; before their obstetrics and gynecology rotation, they will study embryology. In the past, students completed all their training during an orientation in August.
"It's more like just-in-time teaching instead of when we have time," Sheline said. "It's more appropriate to when the students need the information."
The other substantial change to the second year is the addition of one four-week and two two-week elective rotations to give students a chance to investigate various subspecialties that must be declared early. Under the old curriculum, students could not experience electives until year four.
"This gives a degree of freedom to students that they've never had before," said Dr. Edward Buckley, associate dean for curriculum development.
In order to accommodate the intersessions and the additional electives, pediatrics, ob-gyn and psychiatry rotations will be trimmed by two weeks each. Some faculty have expressed concern at condensing these clerkships, but at a May meeting administrators and faculty voted 93 percent in favor of shortening the rotations.
"Shortening any of the core rotations is a tough call," said Ravi Karra, a third-year medical student on the Curriculum Committee. "But some of the time spent now on the wards is not the most efficient for learning."
Year two directors ran a pilot intersession earlier this year to allow fine-tuning of material and to get student feedback. According to evaluations, students found the week interesting but slow-paced. The most well-received portion of the week was the half-day each student spent with a non-physician health care worker such as an exercise physiologist, hospice worker or insurance agent.
"Everyone said, 'If physicians only understood what this person has to offer to patient care,'" Grochowski said. "Our students are learning this before they become actual doctors."
Directors intend to continue tweaking the intersessions to include more case examples--mock diagnostic exercises--and a greater scope of material in each mini-term. Despite the success of the pilot intersession, Sheline said more work is necessary before implementing the planned five intersessions, but she is confident that the terms will be fully developed before the fall 2004 deadline.
"It will only be successful if people have some dedicated time to plan it because it has to be done well," she said. "If we don't do it well, students will just say, 'Put us back on the ward.'"
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