Curriculum reform takes medical school a notch higher for the future

- By Donna Alvarado

Steve Fisch Photography Medical students at Stanford School of Medicine

Medical students are being taught with a curriculum that was updated in 2003 and that integrates classroom learning with clinical training. They are also required to choose a scholarly concentration, or specific aspect of medicine, for multiyear study.

Stanford's medical school curriculum, already known as one of the most comprehensive in the nation, has emerged from an overhaul launched four years ago with a program uniquely poised to prepare graduates for leadership roles in medicine.

The overhaul, begun with the class that entered in 2003, has updated and added requirements to the curriculum. Many medical students already took five years to complete the program before the overhaul and, with the added depth, some academic officials are encouraging even more students to take five years to graduate.

'We believe that to optimally benefit from the Stanford experience, medical students should ideally plan to spend five years,' said Philip Pizzo, MD, dean of the School of Medicine, in his recent newsletter to the medical school community. 'We wish to train tomorrow's leaders across the domains of medicine and science.'

Although the reform of the curriculum began in 2003, academic leaders have been fine-tuning the program ever since. Now they are discussing whether most students will need five years to get the full benefit of the updated research and clinical training in the program.

The hallmarks of the overhaul included the introduction of a scholarly concentration - in which each student selects a specific aspect of medicine for multiyear study - in addition to the core medical curriculum. But the core curriculum itself was also updated to make a more logical progression and to better integrate classroom learning with clinical training.

'We have a packed, rigorous curriculum,' said Neil Gesundheit, MD, MPH, associate professor of endocrinology and associate dean for advising, who worked on the curriculum reform. He does not think, however, that the program necessarily has to take five years to complete. 'The idea was to allow a four-year as well as five-year plan without a faculty bias as to which was preferable, and leave that to student choice,' he said.

Over the past decade, even before the overhaul, about 70 percent of Stanford medical students took more than four years to graduate. If students pursuing double-degree MD/PhD programs are not counted, that figure drops to about 60 percent, Gesundheit said.

The first students to receive their MDs since the curriculum was overhauled were among the class of 2007 that graduated in June, and they accounted for 21 of the total class of 76.

Most of those who started with the new curriculum in 2003 will be graduating in June 2008. Many of them have said that they came to Stanford knowing they would be challenged with a demanding program.

'Students coming to Stanford medical school aren't looking for a 'Happy Meal' curriculum,' said Matthew Goldstein, a third-year medical student who is president of the Stanford Medical Student Association. Although students like to say that the Stanford experience is 'fun,' Goldstein said, 'There's not a single person in my class who's not burning the midnight oil.'

Early results suggest the curriculum overhaul has taken the medical school program, already strong, up a notch higher. One indicator is that students are achieving greater 'Match Day' success - meaning they are matched to one of their top choices for medical residency when they graduate. In June 2007, the match rate was 88 percent for students' top three choices, and 75 percent for their first choice.

A second indicator is that the scores for the medical board exams that students typically take at the end of two or three years have edged up several points since the overhaul. At other medical schools, scores have often dropped fleetingly after a curriculum change until faculty and students adjust to the disruption, Gesundheit said. At Stanford, there was a seven-point rise - from a range of 225-229 before the overhaul to 232-235 after - that, although incremental, suggests an improvement. (A score of 230 is in the 80th percentile nationally.)

'I can't tell you for sure it's cause and effect,' Gesundheit said. But since the overhaul began, he said, 'We've had almost no one fail.'

Last year, Stanford also earned high marks in a big test from a national team that accredits medical schools in the United States. A 205-page report from the Liaison Committee on Medical Education praised the school, and Pizzo, for its commitment to medical education and major curriculum reform.

Curriculum officials say they are continuing to tweak the program to work out all the inevitable kinks that can happen when a complex program is changed. Some of the refinements involve integrating the scholarly concentration program with the core curriculum - to avoid burdening students with an unnecessarily heavy load.

One national education official said many medical schools are reviewing similar issues. 'Schools are revising their curricula and trying to fit that into four years, and finding that a challenge,' said Brownell Anderson, senior associate vice president in the division of medical education at the American Association of Medical Colleges.

But few of the 126 accredited medical schools in the United States are deciding to tell students their programs will take five years. 'I am not aware of many schools taking that approach at the outset,' Brownell said.

Charles Prober, MD, senior associate dean for medical student education since January, has reported data on the experiences of Stanford students who take five years to graduate compared with those who take four. Students who completed their MD in five years were more likely to receive research grants than those who completed their degree in four years (83 percent vs. 66 percent). The five-year students also had more publications (53 percent vs. 22 percent).

The achievements of the five-year students appear to reflect the goal set by Pizzo for Stanford to train the next generation of physicians who join academia and become leaders at the nation's academic medical centers. 'I would like to see the number of our graduates pursuing academic careers increase from the historical 30 percent to at least 50 percent,' he said in a recent interview.

Looking at Stanford's class of 1997, those who took more than four years to graduate were more likely to join academia (33 percent) than those who took four years (26 percent), according to data Prober presented recently to the school's faculty senate.

Pizzo acknowledged there has been some concern that advertising Stanford medical school as a demanding five-year program could discourage some students from applying.

But he emphasized that taking five years to graduate is a flexible plan, and that students still have the option of finishing in four years if they demonstrate valid reasons.

The dean said he has rejected the option of making a five-year program mandatory, particularly after hearing concern that such a mandate could have a negative impact on the broad diversity of students who apply to Stanford medical school.

Those concerned about the cost of an additional year should be reassured that 'doing five years will not add to their financial burden,' Pizzo said, since there are programs available to pay students for their time doing required research. In general, average medical student debt at Stanford is less than half that of other private schools, according to the accreditation report on Stanford last year.

Fernando Mendoza, MD, professor of pediatrics and dean for minority advising and programs, said some students entering Stanford may not realize at first that they might want the option to pursue an academic medical career. But the school's program can give them exposure and resources to broaden their opportunities.

'We want to give students an educational experience that will make them scholars,' Mendoza said. 'This kind of experience can open up doors in the future that wouldn't be open otherwise from a four-year program.' He added, 'That will enhance their future careers as leaders. But it also means acknowledging that's going to take another year.'

Stanford's academic officials recognize the medical curriculum demands a lot of students, yet think it's for a good reason.

'Our school does value the training of leaders who are going to push the envelope in translating medical discoveries into patient care,' said Prober. 'Trying to compress our curriculum and independent scholarly study into four years may be unduly stressful.'

Prober added, 'Stanford educators aim to train physicians who are leaders in all aspects of medicine, including research, advocacy and patient care. We want all of our graduates to be thoughtful, caring, compassionate and humanistic physicians.'

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