Although the School of Medicine has revised many aspect of its curriculum for fall 2004, the only substantial change to the fourth year will be the implementation of a capstone course, designed to epitomize the interdisciplinary nature of the curriculum.
The capstone course will include material from the previous four years and is intended to be a final preparation for students before they leave medical school for their residencies.
"It is designed to review material covered earlier in students' educational experience and weave it together," said Dr. Steve Bredehoeft, an assistant professor of surgery and a member of the Curriculum Committee. He added that the class will also refresh students' knowledge of clinical information and update them about scientific developments that have been made since their classes.
The four-week course will also deal with questions of ethics, law and other issues that will shape their clinical experiences. Although students deal tangentially with these subjects in other years of the curriculum, they cannot fully understand their applications until after students have had practical experience on the wards. Previously, students went straight from their clinical electives to residencies without returning to the classroom to relate their experiences.
The only topic that will move entirely to the fourth year is insurance, which is currently taught in year two.
"Issues on insurance were misplaced in the second year," said Dr. Barbara Sheline, an associate professor of family medicine and a member of the Curriculum Committee. "Students aren't ready to see the big picture in the second year. The timing is better at the end of medical school."
Administrators have not yet begun planning the capstone course, which will not be implemented until March 2005, to prevent exact repetition of earlier course material. The School of Medicine is currently searching for a course director and planning committee, said Colleen Grochowski, associate dean of curriculum development.
The immediate impetus for most of the curriculum changes came from a Nov. 2001 review from the Liaison Committee on Medical Education that required Duke to strengthen its supervision of students' learning and encourage more self-directed learning. However, the development of the capstone course has resulted exclusively from faculty initiative within the School of Medicine.
"The goal was to provide an opportunity to weave together intellectual strands that have presented individually into a final fabric that provides physicians with some comparative complete tapestry from which they can begin to further their professional development," said Bredehoeft, who currently teaches the second-year class that deals with insurance and preventive service issues. He is likely to continue to teach this material when the content shifts to the fourth year.
The capstone course is the final touch to the new, fully integrated curriculum developed in response to the recognition that medicine is increasingly a multidisciplinary field. Since 1967, when the School of Medicine curriculum was last revamped, the boundaries between fields of medicine have become less defined.
"Lately, everyone in medicine has been taking a look at how we can integrate the basic science with the clinical and the clinical with the basic science," Grochowski said. She noted that across the country, medical schools have been moving away from the traditional model of devoting two years to basic science and two years to clinical science, to a structure that better integrates the clinical and basic instruction.
One of the greatest assets of Duke's new curriculum is that issues that appear in multiple aspects of medicine can be interwoven and readdressed throughout the four-year training.
"Something like ethics or geriatrics isn't just a one-time shot," Grochowski said. "It shows up in different ways in different cases. This allows us to revisit the concepts again and again."
The ability to return to concepts is particularly beneficial for Duke's medical school, which is pressed for time to teach basic science because it devotes a full year to research and does not provide excess time to examine the social ramifications of medicine deeply.
"It has been hard for Duke in particular to teach ethics because of the unique third year dedicated to basic science research," said Dr. Jeff Baker, assistant clinical professor of pediatrics and a specialist in medical ethics. "The notion has been that medical education is technical, and we've concentrated on that as opposed to ethics and humanities aspects."
Under the new curriculum, ethics will be periodically discussed both in the abstract and through case examples. The courses will accommodate the practical needs of the med students, providing ethical guidance to issues that they might encounter on the job. Some of the proposed course material includes issues in reproductive medicine, refusal of treatment and care of the dying.
The formal integration of ethics into the medical school curriculum demonstrates the way in which it will continue to look for other ways to broaden the education of students.
"My vision for the medical school curriculum is that it is best viewed as a process, not an end," said Dr. Edward Halperin, vice dean of the School of Medicine and vice chancellor of academic affairs at the Medical Center. "The process of curriculum change and integration is never done."
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