The School of Medicine has developed a concrete schedule for the overhaul of its entire curriculum to be implemented in fall 2004, despite the uncertainty of specifically how and what aspects of the curriculum will change.
Last May, the school's course directors and administrators met with the Curriculum Committee--created to evaluate the old curriculum and recommend a new one--to formally accept the large-scale alterations and create a framework for further development.
Administrators cited the increased complexity of medicine as a profession, the implementation of managed care and evolving philosophies of education-- recognizing that adults learn better through case studies--as reasons for the impending changes. The last time the School of Medicine revamped its curriculum was in 1967.
"We endeavor to both teach a defined body of material suitable for the practice of medicine as well as instill a commitment to lifelong learning in an ever-changing field," said Dr. Edward Halperin, vice dean of the School of Medicine and vice chancellor of academic affairs at Duke University Medical Center.
To that end, the School of Medicine voted to maintain the basic structure of the current curriculum, which devotes just the first year to basic science instruction--whereas most schools dedicate the first two--and the second year to clinical instruction conducted through rotations. This allows Duke to maintain its unique third year devoted to research and still leaves students with a fourth year for clinical electives, which can be completed at hospitals beyond Duke.
The school will combine its 14 first-year basic science courses into three longer, more integrated blocks, add five week-long classroom experiences in the second year, expand its research year from eight to 10 months and require students to return to Duke at the end of their fourth year for a capstone course.
"The goal is to make the curriculum as contextually relevant as possible," said Colleen Grochowski, associate dean of curriculum development, who came to Duke from the University of Arizona College of Medicine about six months ago specifically to aid with the process of restructuring the curriculum. "Integration and contextualization help people retain and apply what they've learned."
In order to maintain Duke's format, the School of Medicine will shorten several of the clerkship rotations in the second year. This plan allows for greater clinical classroom experience but will not allow additional time within the second year for formal basic science instruction after the first year, as the Curriculum Committee had recommended more than a year ago.
The intent was to fully integrate the basic science and clinical information so that the former would essentially be taught through clinical examples and case studies. However, maintaining the current structure "has the effect of limiting the planned innovations in the basic sciences curriculum," according to a summary of the approved changes published after the May conference. All of the mechanisms for integrating these two areas have not yet been finalized.
The changes to the curriculum are in part a response to a Nov. 2001 report from the Liaison Committee on Medical Education--a medical school accreditation association--that labeled the School of Medicine as "weak" in some areas.
"They said we don't have adequate goals that define what our graduates need to know," said Emil Petrusa, associate dean of curriculum assessment. He added that they also suggested a need for more self-directed, discovery learning.
As a result of the LCME's findings and an internal review of the skill set requisite for medicine, the Curriculum Committee, which was formed before the LCME review, set forth a number of substantial recommendations that focused a greater emphasis on independent learning within the context of the integration of basic and clinical science.
The LCME's emphasis on evaluating students' progress more closely during clinical training stems from significant changes caused by the large-scale implementation of managed care in the 1990s, said Dr. Barbara Sheline, an associate clinical professor of family medicine who serves on the Curriculum Committee.
"Part of the problem is that now the attending physicians are so busy taking care of patients that teaching students is the last thing on their minds," Sheline said.
In its curriculum revision process, Duke looked to the University of Rochester as a model. Rochester fully integrated its curriculum beginning in 1999, weaving together basic and clinical science through all four years.
Grochowski pointed to Rochester's innovative model as the forerunner of the new style of teaching medicine. "It seems to be the focus of what medical schools in general are striving for," she added.
When the recommendations were first announced slightly more than nine months ago, many on the Curriculum Committee were worried that they were being implemented too quickly and without sufficient planning. Several administrators and faculty members were concerned that the higher administration was not playing a sufficiently large role in the curriculum's development.
"Some of these changes are substantial and without higher administrative support, we are just whistling in the wind," Petrusa said. He added that since last February, the deans and vice deans have taken a more substantial role in the process.
Officials are continuing to work with course directors and the entire faculty of the School of Medicine to develop and refine the curriculum.
LCME expects an update this January about how Duke is addressing its weaknesses. However, getting the LCME's stamp of approval is a necessary, but not final, step.
"As soon as we implement new modifications in our curriculum," Halperin said, "it will be time to turn our attention to yet another set of changes as medicine and biologic knowledge change."
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