Grochowski, Colleen O’Connor PhD; Halperin, Edward Charles MD, MA; Buckley, Edward George MD
The Duke University School of Medicine curriculum is unique. Students learn the core basic sciences in the first year, complete core clinical clerkships in the second year, devote the entire third year to scholarly investigation, and fulfill elective rotations in the fourth year. By condensing the traditionally structured training from four years into three, we provide students ample opportunity to pursue independent scholarly interests; our goal is to entice them to pursue careers as medical educators and/or investigators. However, aspects of our condensed curriculum, discussed in detail later in this article, could be adopted to achieve a wide array of institutional goals. In our opinion, similar curriculum models could be applied to simply shorten the length of medical education or, depending on a medical school’s mission, to achieve other institutional agendas, such as broadening students’ exposure to other disciplines or allowing them to pursue opportunities in global health.
Duke’s current curricular structure is a result of an ongoing process of evolution that began with the inaugural curriculum in 1930. Duke’s founding curriculum was derived from the Johns Hopkins University School of Medicine because the majority of Duke’s first faculty members were recruited from that institution.1–3 About half of the hours of the initial Duke curriculum were consumed with required courses, and the remainder were devoted to electives—a ratio similar to the Hopkins curriculum at the time.4 During the next 30 years, Duke placed increasing emphasis on basic science and on the understanding of the patient and the social environment. During this period, the amount of time devoted to electives and free time shrank considerably.5
A confluence of forces, events, and personalities came together from 1955 to 1965 that would radically change Duke’s curriculum. A cadre of Duke faculty took it upon themselves during the course of those 10 years to promote curricular reform. These men—William Anlyan, Philip Handler, Jerome Harris, Thomas Kinney, David Sabiston Eugene Stead, Jr., Daniel Tostesen, and James Wyngaarden—played prominent roles not only at Duke, but in the field of medicine. Handler, who was then chairman of biochemistry at Duke, would go on to become the president of the National Academy of Sciences and a recipient of the National Medal of Science. Thomas D. Kinney brought to Duke his experience from the Western Reserve University in interdisciplinary teaching methods, basic science instruction focused on the mechanism of disease, and self-education. He came to Duke from Western Reserve in 1960 as chairman of pathology. Stead became chairman of medicine at Emory in 1942 at the age of 34. By 1946, he was dean of Emory, but he left one year later to begin a 20-year term as chairman of medicine at Duke. Wyngaarden would go on to succeed Stead as chairman of medicine and become the director of the National Institutes of Health. Anlyan was the dean at Duke at the time; Harris was Duke’s chair of pediatrics; Tosteson, Duke’s physiology chair, later became dean of Chicago and Harvard; and Sabiston became chair of surgery in 1964. These influential people initially joined together around their dissatisfaction with Duke’s medical education program. In reviewing the Duke curriculum, they concluded:
The curriculum had become intellectually confining to the student and too highly standardized. It occupied all the available time; it treated all students as though they were identical and interchangeable both on entry and throughout the four years of medical school; it allowed for little expression of individual growth rates and awakening interests … our curriculum seemed in many ways at cross purposes with the principles of higher education that should foster the creative and scholarly development of the individual student and future physician.6
A time for change had arrived.
Establishing a Precedent of Innovation
This nucleus of innovators worked as an informal team to promote a new curriculum that would reflect the values that each brought to the reform process on the basis of his own previous experience. Kinney articulated the proposed curriculum reform in a 1971 essay:
The only practical solution is to prepare each student so that he will be able to acquire new scientific information when he needs it. This means that he must learn to evaluate critically the worth of new information as well as its applicability to the problem at hand. In short, the basic science experience should be designed to help the student develop the ability to ask questions and to ask them, and to acquire something more than a collection of facts that are likely to be outmoded in a short period of time … Curriculum reform in the basic sciences revolves around these fundamental questions: what are the basic sciences germane to the practice of medicine and why are they supposed to be more basic than other medical sciences? Just what are the responsibilities of our basic science teachers? What is the scientific relevance or usefulness of the subject material when taught in a world radically different from the placid academic world of the past where research was a password to academic achievement?7
The proponents of the new curriculum also wanted to shift emphasis away from rote memorization. On the basis of his experience in World War II training medical students in a three-year program, Stead championed the notion that most facts need not be memorized because they are quickly forgotten. Instead, he argued that students need to learn how to learn what they need when they need it. He generally referred to this concept as the forgetting curve (i.e., the students quickly forgot facts that they did not use on a regular basis).8–11
Consequently, the group of reformers recommended an abbreviated required curriculum consisting of the core basic science classes in the first year of medical school and the core clinical rotations in the second year. The third and fourth years would offer students a choice among a series of multidisciplinary learning experiences. The student would be free to arrange his or her work during these two years in any sequence of clinical and preclinical experience he or she chose, thus making these last two years of medical school a single, integrative learning experience.5,12 Handler argued that this curriculum reform would correct the shortcomings of the “increasingly recognizable, serious inadequacies” of the current program of medical education:
Flexibility is substituted for rigidity, experience in depth for superficial and easily forgotten acquaintanceships with course material, critical habits of thought for easy acceptance of didactic material, individual experience for mass indoctrination, a common basic experience in all individuals concerned with medical education for quite disparant [sic] programs involving basic medical science careers as opposed to that of the clinician or clinical investigator, and hopefully the establishment of a lifelong mature habit of learning for complacent satisfaction in the mass of information already acquired…. The new curriculum is firmly rooted in the obvious psychological fact that the student himself is the final common integrator of his knowledge of medicine. No rearrangement of the material by the faculty can succeed in providing him with an integrated grasp of medicine unless the student himself is able to perform the act of possession.13
The new elective curriculum (1966)
The revised curriculum (Figure 1) was implemented in 1966 and offered more academic options, marked flexibility, early clinical exposure, increased research opportunities, and could be tailored to a student’s ultimate career goals. The first year consisted of the core basic science courses and was divided into two semesters. In addition, there was an introduction to clinical medicine course that spanned both semesters. The second year consisted of eight-week core clinical clerkships in the major disciplines. The last two years consisted of one year of basic science electives and one year of clinical electives, which could be taken in any order.
The basic science faculty faced the hardest initial challenge in creating the new curriculum. They had to determine which basic science material was truly core material and must be in the first year, and which material could wait until the third or fourth year or did not need to be taken at all. To accommodate the change, the clinical departments just shortened their rotations, because their focus was the clinical experience, rather than any prescribed content.
The anatomy debacle
The introduction of the new curriculum in 1966 affected the department of anatomy more than any other basic science department. Before the curriculum reform, 531 hours in the first year had been assigned to the teaching of gross, microscopic, and neuro anatomy. The reform reduced the hours devoted to anatomy to a total of 252. Of the 252 hours, 100 were devoted to gross anatomy, 100 to microscopic anatomy, and 50 to neuro anatomy. Gross anatomy suffered the greatest loss of time with the new curriculum. Many members of the anatomy faculty considered it impossible to cover the subject under the new curricular model.
After considerable discussion and review of the way in which gross anatomy was being taught at Western Reserve, the anatomy department created specially equipped tabletops with large magnifying glasses for the dissection of fetuses. Instructors performed prosections on adult cadavers and made extensive use of audiovisual models in an attempt to cover the material in 100 hours. After one year of this reform, Dr. Robertson, who was then chair of anatomy, frankly admitted:
The experiment was a complete failure. The students complained endlessly that they could not see what they were supposed to see in the fetuses and that fetal anatomy was different from adult anatomy … the faculty complained about the physical facilities … the constant complaints from both students and faculty convinced [me] of the necessity of reorganizing the course.14
The next year, the faculty attempted to make the course as clinical as possible. Relying entirely on lectures, demonstrations, models, audiovisual materials, and prosections, this more clinical course also failed because of a lack of continuity between the lectures.
On a third attempt, assistant professor Jack Hale Prost laid out a complete plan for dissecting a body.15 He performed the dissections personally and timed each one. At the end of 80 hours, he accomplished what he considered to be a complete dissection of a cadaver, encompassing the necessary topics for a standard medical school course, and his model was implemented as the new anatomy curriculum in 1969.
However, this third experiment also seemed to be a failure. The students complained that, because of the condensed anatomy curriculum, they would be inadequately prepared for clinical work. Robertson concluded that
The source of trouble was not conceptual but rather a problem of personal interactions. Certain of the older staff members were allowing their bias against the new approach to be communicated to the students. They were convinced that memorization of detail was in fact necessary. This affected the students profoundly.14
Two more anatomists were hired to attempt a fourth iteration of the course. Although it met resistance from students and older staff members, this course had succeeded by using the 80-hour dissection with clear procedural instructions for dissection. This design furnished the basis for the final, successful anatomy course model, and for the 1987 textbook Human Structure, which has been used at Duke and other medical schools.17 Today, 40 years later, gross anatomy is still taught at Duke, with about 80 hours of dissection and 15 hours of lectures.
The evolution of the research year
The evolution of the research year actually predated the organized process for curricular reform. In 1955, before he and his colleagues joined around the mission of curricular reform, Handler began to assert that the medical curricula should make specific provision for the training of a subset of students as basic science faculty members as well as clinician–investigators. Handler proposed an intensive nine-month training period, which the students would enter any time after the first two years of basic science instruction. Students would perform a series of experiments under the guidance of specialists. In the first four months, the students would be given an overview of basic research tools. In the next five months, each student was required to design and undertake a small research project of his or her own, involving more than one discipline. The laboratory experience was to be complemented by correlative seminars.16 The biomedical research training program was initiated in 1959 in accordance with Handler’s proposal. Within the next two years, 16 medical schools had sent visitors to observe the program. Under the direction of Wyngaarden, it flourished.5,6,16
This original research training program was popular, but it delayed students’ exposure to the clinical rotations. Handler and Wyngaarden reported that “some students have shown ambivalence about spending an academic year in research training before they had the opportunity to gain a grasp of the clinic. For years they had looked forward to being medical students in contact with patients and they were loathe to defer this experience.”6
In 1962, in response to the students’ feedback, students were allowed to enter the research training program after the third year instead of the second. This modification laid the foundation for the current curricular design. By allowing the students to experience clinical care before undertaking a research experience, they were more likely to approach the research opportunity from a clinician’s perspective of how the experience could be used to improve care.
With the 1966 curriculum revision, the previous research training experience was incorporated into the basic science elective time, and basic science credit was given for it. Initially, about half the class opted for traditional basic science elective courses and half for the research program. As was predicted by some, students had trouble focusing their elective choices around a goal, and the elective years became disjointed. This disorganization was remedied in the 1970s by developing multidisciplinary study tracks that outlined a course of study for students in their elective years. The first tracks, which combined research opportunities with basic science courses, were neurobiology, cancer, genetics, cardiovascular, immunology, and pathology. These tracks became popular and eventually replaced the random selection of basic science electives.
By 1980, the entirely elective third and fourth years of the curriculum evolved. They were finally organized around a third-year scholarly experience, plus a fourth year of clinical electives. This model retained significant flexibility in designing an individual learning program and, at the same time, eliminated the sometimes random selection of disjointed courses. The third year had evolved into a true research year with opportunities in clinical and basic science research as well as opportunities to obtain additional graduate and professional degrees. The third-year scholarly experience was individually designed to match the goals of the faculty mentor and the student. Typically, mentors would assign an aspect of their ongoing research to the student, who was then responsible for conducting the experiment(s), gathering and analyzing data, and reporting on findings in manuscript format.
The block system (1992)
By 1992, advances in scientific knowledge required students to learn more material. In the first year, students took the required semester-long courses, each taught independently of one another. Students were having difficulty assimilating the material across courses. In an effort to facilitate learning, faculty decided to concentrate the material into blocks of a few courses in each. Five blocks were created, each building on the material taught in the previous block. Biochemistry, cell biology, and genetics were selected to be in the first block, because faculty felt that these subjects were fundamental to the remainder of the students’ medical education. This was followed by material related to the normal function of the human body, such as anatomy and physiology. Lastly, students learned material related to disease states and therapeutics, such as pathology and pharmacology. This block system served to focus the learning efforts of the students, because they could now concentrate on fewer subjects at a time.
The Foundation for Excellence Curriculum (2004)
As time passed and the knowledge base continued to expand rapidly, curricular leaders recognized that traditional boundaries between academic departments no longer reflected the ways in which science or clinical care were organized. To keep pace with the changing knowledge base, leaders believed that a more integrated cross-disciplinary approach would better prepare students for the scholarship and clinical experiences ahead. Therefore, Duke underwent a comprehensive curricular reform process in the late 1990s. Faculty and staff participated in a series of curriculum retreats to assess the current status of the curriculum and to make recommendations for change. These retreats resulted in several overarching curricular goals: to organize the basic science instruction around organ systems; to integrate basic science and clinical instruction; to incorporate interdisciplinary, nondepartmentally based topics relevant to the practice of medicine; and to expose students to the fundamentals of health care teams.
The 2004 curricular reform process began with the decision to define core concepts to be included in the curriculum, rather than to flesh out traditional categories of educational units. Retreat attendees identified the following core concepts as those that should be included in the curriculum: molecules and cells; normal body; body and disease; clinical areas, including clinical skills, acute/inpatient/emergency medicine, chronic illness, intensive care, and prevention/ambulatory medicine; diagnostic technologies; professionalism; medical ethics, humanities, and the law; and scholarly activities. In addition to curricular changes, leaders identified the need for change in several areas of Duke’s infrastructure: assessment, guidance and coordination, educational technologies, logistics and resources, educational methodologies, and student life.
With these specific goals in mind, a new associate dean for curriculum development (E.G.B.) was hired to lead the reform effort. The leadership formed subcommittees to address each core concept. The new associate dean chaired a new curriculum committee, which consisted of the chairs of each of the subcommittees. Each subcommittee was charged with developing learning goals and objectives for the core concepts that were ultimately condensed into 233 objectives to which each element of the new curriculum was tied. Over the next several years, and with the full support of the dean and the leadership of the vice dean for education, hundreds of Duke faculty members and students working within these subcommittees developed the Foundation for Excellence curriculum that was implemented in fall 2004.
One of the initial steps in crafting the new curriculum was to consider whether to retain the year-by-year structure of the curriculum initiated in the 1960s. The faculty and school leadership quickly decided that the research year was essential for creating physician scholars. They saw the research year as the factor that sets Duke apart from other medical schools. Faculty members and leaders soon realized that the 2004 curricular reform would be built around the third year—suggestions to rearrange and/or shorten the third-year research requirement were dismissed as weakening the in-depth research experience desired of all Duke medical students. Because of the length of the research year (a minimum of 10 months), it was clear that moving this experience was impossible, given the principles that basic science instruction must precede clinical clerkships and that clinical clerkships must precede and inform scholarly investigation. The scholarly year could not split the students’ completion of clinical clerkships insofar as delayed completion of the clerkships would hamper their career decisions. Lastly, academic calendars for Duke’s medical school and its main campus had to align to allow students the option of enrolling in an additional degree program.
Thus, leaders set out to reform Duke’s curriculum around its unique research year. In the resulting Foundation for Excellence curriculum, first-year basic science courses were integrated around topics rather than disciplines. Elective periods to assist students in career exploration and an interdisciplinary course focusing on clinical reasoning and the challenges of cross-specialty care were introduced into the second year. The third year was lengthened to allow for greater student involvement in a scholarly pursuit. Finally, an interdisciplinary capstone course, reviewing and reinforcing key concepts and skills, was added to the fourth year. Overall, the Foundation for Excellence curriculum places greater emphasis on developing problem-solving and data-analysis skills, as well as how to work in a team environment (Figure 2). Changes to all four years were implemented simultaneously.
Before 2004, Duke’s first year consisted of 11 departmentally based basic science courses organized in blocks, without interaction among the course directors. Although it was logical given the organization of the basic science departments, the block system resulted in related material being taught at different times during the first year, redundancy, and poor integration of clinical information with core basic science material. Consequently, students had difficulty using basic science information for clinical problem solving. Critical subject areas, such as the pathophysiology of disease, epidemiology, and human development, were not adequately covered. In the second year, clinical faculty were having to devote more of their time to patient care, leaving less time to provide didactic instruction during the students’ clinical training. Thus, teaching responsibilities traditionally assigned to the second year were falling increasingly on the first-year courses. Departmentally based courses were ill equipped to handle these new responsibilities.
With these problems in mind, the course directors refashioned the 11 courses into four integrated courses that flowed from cellular and subcellular to organ-level units of normal anatomy and physiology, to systemic pathological processes, to organ-specific pathology and therapeutics. The four courses are Molecules and Cells, Normal Body, Brain and Behavior, and Body and Disease. The integration allows students to learn, in context, the basic science principles and their application to the clinical practice of medicine (see below).
Molecules and cells.
Molecules and Cells is six and a half weeks long and focuses on the molecular and cellular principles of human disease. This integrated course progresses from DNA to mRNA, to protein, to organelle, to cell, to tissue, and includes the musculoskeletal system. Each week’s topics are considered from the disciplines of biochemistry, cell biology, and genetics and include at least one histology lab and one patient presentation or clinical correlate that incorporates the basic science principles from all three disciplines and demonstrates how these principles will be manifest in the clinical setting.
The 13-week Normal Body course integrates normal physiology, microanatomy, gross anatomy, and embryology. Normal Body covers the normal structure and function of the body as an intact organism, and each of the body’s specific organ systems. Students learn to recognize and explain the basic concepts and principles that govern the structure and function of each organ and organ system, and how the organ systems are integrated to maintain homeostasis. Nine organ systems are covered: cardiovascular, respiratory, integument, defense, gastroenterology, renal, endocrine, reproductive, and peripheral nervous system. Learning methodologies in Normal Body are highly interactive. Students participate in laboratories, symposia, and problem sets (modified team-based learning, including individual and small-group quizzes, and group exercises requiring the application of newly mastered basic science principles to clinical scenarios). Cadaveric dissection in the gross anatomy lab follows as closely as possible the organ systems being studied.
Brain and behavior.
In the four-week Brain and Behavior course, students learn about the organization and function of the central nervous system from the molecular to the systems level. Students have the opportunity to slice and examine brains from the cadavers they dissected in the gross anatomy lab. Concurrently, instructors present content about personality, reward and motivation, and the somatic sensory system. The neurobiology laboratory provides the means to integrate the underlying principles with hands-on exercises and to discuss the effects of trauma and disease. Instructional technology resources are available to students throughout the course, including a Web-based lab manual, an interactive brain atlas, and a glossary of applications.
Body and disease.
Body and Disease is the last 20 weeks of the first year. Students gain an understanding of disease processes, diagnosis, and treatment of human disease. The course is divided into an initial seven-week block focused on basic principles of the four disease-related basic sciences—immunology, microbiology, pathology, and pharmacology—followed by a series of units devoted to diseases of specific organ systems. The latter units serve to reinforce and expand the students’ knowledge of basic science in the context of human disease. The course incorporates several active teaching methodologies, including workshops that feature actual patients.
Practice course I
The Practice Course is a three-year interdepartmental longitudinal course beginning in year one that introduces students to basic and advanced clinical communication skills, physical examination skills, the meaning of illness, and clinical reasoning. This course is conducted in small groups and stresses active learning of new skills, self-learning, and cooperative learning in a supportive environment that encourages self-reflection. Small learning groups remain intact throughout the first two years. The first clinical preceptorship takes place in ambulatory care settings during the spring of year one.
In spite of the streamlined one-year basic science curriculum, only 35% of the first-year curriculum is didactic. Twenty-five percent involves active, participative learning in small group and laboratories, and one third of the students’ first year is devoted to independent, self-directed learning. The rest of the time is devoted to assessment.
A broad-based clinical training task force of the curriculum committee recommended curricular innovations in year two to enhance the integration of basic and clinical sciences; to provide interdisciplinary, team-based education and structured clinical reasoning experiences; to address critical interdisciplinary topics not covered elsewhere in the curriculum; and to provide elective periods allowing for exposure to clinical subspecialties not encountered during core clerkship rotations. When the curricular reform effort was initiated in the late 1990s, reformers strove to create clinical training for students according to the various aspects of clinical care—acute, chronic, ambulatory, and preventive. These integrated and interdisciplinary innovations, however, could not be supported by the departmentally driven graduate medical education system in which the clinical aspects of undergraduate medical education are based. Consequently, we had to shorten several of the clerkship rotations. To help decide which clerkships to shorten, we looked at the national average length of clerkships. In light of this information, we decided to shorten pediatrics and obstetrics–gynecology to six weeks each, and psychiatry and community and family medicine to four weeks each. Medicine and surgery rotations remained eight weeks long.
Clerkship directors were concerned about the proposed revisions. Although shortening those clerkships created time to address specific curricular deficiencies, it also created new challenges. For example, in the new model, each rotation had to accommodate more students in venues that were near or at full capacity, and clerkship curricula had to be reorganized to fit within a shorter time frame. Nonetheless, clerkship directors adopted the reform initiatives with a commitment to closely monitor attendings’ feedback and students’ performance on benchmark exams.
Orientation to the clinical year.
Students begin their second year with a two-week Orientation to the Clinical Year (OCY), where they are introduced to the basic skills sets they will need on the wards, including laboratory tests, radiology, electrocardiograms, clinical computer use, blood drawing, and the approach to common clinical problems. Students practice history and physical examination skills on ward patients, and then they make oral and written presentations to fellows and faculty. OCY lecture topics cover several issues, including professionalism and diversity.
Clinical core courses.
Students attend the first of five one-week Clinical Core Courses in the week after OCY. The Clinical Core Courses are designed to help students develop clinical reasoning skills, integrate knowledge to solve problems outside the confines of a single discipline, develop skills and attitudes for effective interdisciplinary teamwork, prepare for upcoming clerkship experiences, and learn interdisciplinary content not otherwise covered in the curriculum. Throughout the Clinical Core Courses, instructors apply various teaching methodologies, including skill development sessions, presentations by patients and their providers, team-based learning, and mock interdisciplinary conferences. Students also complete health care team visits in which they spend a half-day with a nonphysician health care provider to learn the nature and challenges faced by those in various health professions with whom they will be working in the future. Each Clinical Core week has a theme—patient safety, aging, clinical oncology, critical care, and disaster preparedness—and occurs in the week immediately preceding each clerkship rotation block.
Core clinical clerkships.
After the first clinical core course, students begin clerkship rotations as described above. All clerkships except medicine include outpatient experiences, and each has a didactic component. Student performance is assessed through preceptor evaluations, written and/or shelf exams, and student projects or presentations.
Twice during their second year, students have the opportunity to complete a two-week selective intended to familiarize them with clinical specialties other than those in their core rotations. There are currently 30 selectives from which to choose, including ophthalmology, radiology, orthopedic surgery, and pathology.
In May, second-year students have a four-week elective rotation. Students may choose from among many of the fourth-year elective offerings, excluding those with unmet prerequisites. Second-year students can be accommodated in the clinical setting as fourth-year medical students have graduated in May. Given that students spend their third year in focused scholarly activity and do not return to clinical rotations until June or August of their fourth year, this four-week elective in the second year provides students with an opportunity to investigate possible career choices early in their training. This opportunity is particularly beneficial to students considering specialties that participate in the early match.
Practice course II.
The Practice Course in year two covers professionalism, end-of-life issues, pain management, advanced doctor–patient communication, maintaining a sense of self, and art and medicine. Students prepare for and direct the small-group discussions. The small groups also serve as a place of reflection and support during the busy clinical year.
The second year concludes with the assessment week. Students’ clinical skills are evaluated in an eight-station clinical performance examination with standardized patients, a written examination on the content covered in the clinical core courses, a medical informatics test, and the Comprehensive Basic Science Exam (CBSE). Students also are assessed on their ability to read electrocardiograms and x-rays. At the end of the week, clinicians review the correct responses with the students. Additionally, students complete a leadership self-assessment and participate in a retreat with their advisory deans to reflect on the educational impact of the second-year curriculum.
The goal of the third year is to provide a rigorous 10- to 12-month scholarly experience in biomedically related research. Each student pairs with a preapproved mentor and takes responsibility for an aspect of the mentor’s ongoing research. Students can pursue one of 16 study programs, which are all designed to provide the students with in-depth exposure to science. Research options within each study program range from a small research project associated with a structured curriculum of course work and seminars to an unstructured curriculum focused around a research question. It is the responsibility of the student, with the guidance of a study program director and mentor, to identify the curriculum necessary to properly explore a particular research question. To successfully complete the third year, each student must complete an online medical statistics course. Each student is required to submit a written thesis by the end of the year detailing his or her contribution to the research project and outlining the findings. All students also are required to verbally present their third-year research projects at medical student research day, departmental research conferences, or national meetings.
Students also have the opportunity to pursue an approved additional degree program: doctor of philosophy, master of business administration, master of public health, master of public policy, master of science in library sciences, master of arts in liberal studies, master of arts in psychology, juris doctor, or master of science in clinical research. Approximately one third of Duke medical students earn an additional degree.
Students complete the course requirements for the longitudinal practice course in a continuity clinical preceptorship in year three. This preceptorship requires students to participate in a once-a-week outpatient experience for 34 weeks. The goal of this experience is to understand continuity of care and outpatient disease management over time.
During their fourth year, students are required to complete a subinternship, a critical care selective (ICU, anesthesiology, or emergency medicine), and five four-week electives. The year culminates with a four-week capstone course that addresses issues organized around the American Council for Graduate Medical Education core competencies: patient care (including practical tips for functioning when on call as an intern), basic life support, and advanced cardiac life support; medical knowledge about established and evolving biomedical and clinical sciences; practice-based learning and improvement regarding patient safety, medication safety, and medical liability; interpersonal and communication skills training about effective information exchange and teaming with patients, their families, and other health professionals; professionalism relative to responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population; and systems-based practices focusing on one’s understanding of and responsiveness to the larger context and system of health care.
Effect of Curriculum Changes
In light of Duke’s reorganization and integration of the basic science curriculum, we have closely monitored student performance against national benchmarks. Students complete the National Board of Medical Examiner’s CBSE at the end of years one and two. We have noted a sustained significant increase in CBSE scores at the end of year one with the implementation of the Foundation for Excellence curriculum, suggesting that the integrated basic science curriculum is resulting in a deeper understanding of basic science principles. We have also noted that students’ CBSE scores have markedly increased at the end of year two, suggesting that students’ understanding of the basic sciences is reinforced in their clinical clerkships.
Duke students who began their medical education with the implementation of the Foundation for Excellence curriculum have not yet taken the United States Medical Licensing Examination Step 1, 2CK, or 2CS. We will continue to monitor student performance on national benchmark exams.
Because one of Duke’s goals is to develop academic clinicians, we have chosen publication frequency of our graduates as one metric for measuring our success. We have found that nearly two thirds of Duke graduates publish at least one scholarly peer-reviewed article during medical school, and many are still publishing 20 years after graduation. We anticipate this pattern to continue, given the increase in length of the research-based third year in the Foundation for Excellence curriculum.
All students are required to complete a course evaluation as they finish each course in the curriculum. The 2005–2006 course evaluation data, based on the second full year of the Foundation for Excellence Curriculum, indicate that students are happy with the new curriculum. Students report general satisfaction with each of the integrated basic science courses—an average of 88% agreed or strongly agreed that each course supported their achievement of the learning goals and objectives; 79% of the students likewise rated the core clerkship rotations. Seventy-two percent and 79% of second-year students rated selectives and electives, respectively, to be valuable learning experiences. Overall, second-year students rated clinical core courses a 4.1 on a 5-point scale (1 = low/strongly disagree, 5 = high/strongly agree) for achieving stated learning objectives. Ninety-one percent of third-year students rated their scholarly experience as good or excellent. Fourth-year students rated their learning in the capstone course an average 3.5 on the 5-point scale.
Faculty, too, report satisfaction with the new curricular model. In a faculty retreat after the first year of the new curriculum, year one course directors reported success with the integrated, organ-based delivery of content; the inclusion of additional clinical correlations; and the increased opportunities for more active learning. Their concerns included the lack of a unified grading system, the timeliness and quality of course evaluations competed by students for courses that were 16 and 20 weeks long, and the continued redundancy of some topic areas.
Year two course directors favorably evaluated the inclusion of selectives and electives in the second year. They also were positively impressed by the clinical core activities, including the students’ exposure to patients and family members, shadowing non-MD health care providers to learn about the nature of the health care team, and time devoted to preparation for the clerkships. The course directors have continuing concern about the need to repeat the clinical core didactic instruction 5 to 10 times over the year; providing more time in preclerkship activities to practice complete physical exams, write-ups, and clinical reasoning; the loss of time for psychiatry and neurology; and the need for more students to complete their rotations at a faster pace in the same number of venues.
Continuing the Tradition of Innovation
Forty years ago, medical education leaders at Duke began a bold experiment to increase the opportunities for medical students to tailor their education to serve students’ personal interests and career goals. The elective curriculum of 1966, although retaining considerable freedom of choice, has been reshaped over the years into a curriculum that strives to involve the student in the pursuit of the knowledge on which clinical decisions are based. By shortening the time spent in learning the basics, we have created opportunities for students to study areas in depth, exposing them to the exciting possibilities of an academic career before the demands of postgraduate training are encountered. We feel that this added opportunity in medical school provides a distinct advantage in helping students decide whether to pursue a research or academic career and facilitates these career decisions.
In concentrating core basic science instruction into one year, we have saved a year and have chosen to use it to foster scholarly pursuit. Other institutions, if they follow the format of our curriculum, may choose to use the year saved to achieve their own unique goals.
Because of the looming shortage of academic and primary care physicians, the rising costs of medical education, and the resulting indebtedness of medical school graduates, many educators are seeking ways to streamline medical education. If strategically combined with educational innovations along the path from undergraduate to graduate medical education, an abbreviated curriculum could be used to fast track both clinicians and clinician–researchers by shortening their required education. Schools with the principal mission of producing primary care physicians could adopt a one-year model of basic science instruction to allow their students to begin an integrated residency program after just three years instead of the traditional four. In addition to getting physicians more quickly into practice, a shortened educational experience also would result in a decrease in student debt—a particularly appealing option at a time when federal loan and scholarship monies are becoming scarce.
The Foundation for Excellence curriculum model has achieved Duke’s mission of training clinician–researchers and clinician–educators. We believe that a one-year basic science curriculum can similarly address the diverse needs of other institutions as well.