A redesigned curriculum for Stanford medical students is now being fully implemented. It provides new courses, more flexibility and financial incentives for pursuing long-term research.
September 12, 2018 - By Julie Greicius
A new curriculum at the School of Medicine is transforming the way medical students learn and prepare for careers in clinical care and scientific investigation.
The Discovery Curriculum resulted from a three-year review of the curriculum that involved more than 100 faculty, staff and students. The goal was twofold: first, to create opportunities and flexibility for students’ long-term research, personal growth, exploration and discovery; and second, to improve the quality of coursework and teaching, and to close curricular gaps that were identified during the review process.
“The students, faculty and Nobel laureates who developed our Discovery Curriculum are true innovators in medical education,” said Lloyd Minor, MD, dean of the School of Medicine. “Their efforts will facilitate pursuits of fundamental discovery that further our precision health vision, provide our students with a more flexible and distinctive learning experience, and expedite the preparation of physician-scientists to become leaders in biomedical investigation.”
Physician-scientists balance their time between research and clinical care. They usually work at academic medical centers, in settings where their clinical practice can inform their research and vice versa.
Expediting physician-scientist training is more important than ever, given the dwindling number of clinical investigators in the workforce, said PJ Utz, MD, professor of immunology and rheumatology and associate dean for medical student research. “Over the last 15 years, the number of physician-scientists aged in their 40s went from about 7,000 down to about 4,000,” Utz said. “And the numbers of those who are in their 60s, 70s and 80s increased. By our analysis, close to 200 additional physician-scientists need to be trained every year than we are currently graduating across the nation.”
A 2014 report from the National Institutes of Health detailed the challenges weighing on the physician-scientist workforce — such as longer training times and increasing educational debt — and noted that “the largest group of NIH-funded U.S. physician-scientists continue to be those who hold an MD as their only professional degree.” The report highlighted the value of physician-scientists, noting that those who both see patients and perform research can “help identify the mechanisms of disease, as well as apply the findings of basic science to patient care.”
The School of Medicine’s new curriculum is designed to introduce research to medical students earlier in their training to support their goals for learning and discovery without requiring them to spend the seven to eight years needed to complete an MD-PhD program. The redesign committees also sought to make the curriculum more flexible, re-engage basic scientists in teaching, continuously improve the quality of teaching across the board, and foster scientific investigation while maintaining students’ clinical training and preparation for residency.
“Students come to Stanford knowing about its prestige in investigation and discovery,” said Paul Berg, PhD, professor emeritus of biochemistry and a co-recipient of the 1980 Nobel Prize in chemistry, who played a major role in shaping and championing the new curriculum. “We want to instill that same culture into the medical students. And my own experience is: Any success early hooks you. You get somebody who makes an interesting discovery, writes an interesting paper and gets it published — that sticks.”
Quality research is longitudinal
While Stanford has long required a single quarter of scientific research as part of the criteria for medical students to graduate, the previous curriculum did not allow flexibility for longer research projects. Students who engaged in long-term projects typically took a full year off to complete them, disengaging from their classmates and coursework. Daniel Bernstein, MD, professor of pediatric cardiology and associate dean for curriculum and scholarship, noted that quality scholarship “often depends on an experience that’s longitudinal.”
Typically 75-85 percent of medical students at Stanford have opted for at least one extra year of medical school to incorporate additional scholarly pursuits, Bernstein said. “When I arrived at Stanford over 30 years ago, this approach was unique among medical schools, and today it still is unique,” he said.
Students who choose the MD-PhD program, also known as the Medical Scientist Training Program, spend their first two years in medical education before starting full-time laboratory research. After three to five years of research, they complete and defend their PhD thesis before finishing their the last two years of medical training, which are dedicated to clinical rotations. Stanford MD-PhD students are fully supported through the entire program by a combination of funding from an NIH training grant, individual graduate programs and School of Medicine funds.
“Our students have always been keen to do research,” said Neil Gesundheit, MD, MPH, professor of endocrinology and senior associate dean for medical education. “The dream of each student is, in the process of research, to come up with a discovery that has the potential to change practice, be innovative and improve people’s lives.”
Envisioned by Nobel laureates
The Discovery Curriculum began as the vision of a small team of faculty that included Utz and Berg, along with Brian Kobilka, MD, the Hélène Irwin Fagan Chair in Cardiology, professor of molecular and cellular physiology and co-recipient of the 2012 Nobel Prize in chemistry. Participating in the early stages of the curriculum’s development were Russ Altman, MD, PhD, the Kenneth Fong Professor and professor of bioengineering, of genetics, of medicine and of biomedical data science; Andrew Fire, PhD, the George D. Smith Professor in Molecular and Genetic Medicine, professor of pathology and of genetics and co-recipient of the 2006 Nobel Prize in physiology or medicine; and Donald Regula, MD, professor of pathology.
“The curriculum had been very inflexible,” Kobilka said. “And I noticed that students rarely came to my lab to ask about doing some basic research as part of their experience.”
Kobilka also noticed that Stanford Medicine’s basic scientists had gradually become less involved in teaching, and that troubled him. “Stanford is a special place,” he said. “It’s a place where students can have access to cutting-edge research when they’re in medical school, partly because it’s a great university and also because the basic science departments in the medical school and undergraduate campus are all contained in a very small geographic footprint. The inflexible curriculum made it difficult for students to take advantage of all that Stanford had to offer.”
The group also noted that an increasing number of medical schools were moving to reduce the time necessary to complete their medical degree programs from the traditional four years down to three in response to a growing shortage of clinicians — a shortfall projected by the Association of American Medical Colleges to reach 100,000 by 2030. But the Stanford group believed that, for a research-intensive medical school like Stanford, it was urgent to do the opposite: reaffirm Stanford’s commitment to scholarship and discovery and create a pathway for physician-scientists that would be an alternate to the MD-PhD, which takes longer, costs universities more and often draws graduates away from clinical work entirely into laboratory research.
“At Stanford, we pride ourselves on being the most research-intensive medical school in the world,” said Utz, who graduated from the School of Medicine in 1991. “To advance medicine, scholarship is essential.”
New curriculum takes shape
The group’s early conversations took shape as Gesundheit and two administrative committees championed by the dean aided the effort to formalize a plan, leading to the first major overhaul of the curriculum in 15 years.
“From our earliest conversations, Dean Minor was focused on the future possibilities of a new curriculum,” Utz said. “He could see the need for a uniquely Stanford balance between scientific investigation and superlative clinical training, and helped to ensure it became a reality.”
Preetha Basaviah, MD, clinical professor of medicine and assistant dean for pre-clerkship education, and Bernstein co-chair the committee charged with implementing the Discovery Curriculum. Basaviah spent a decade as one of the directors of the Practice of Medicine course, which began in 2003 and now makes up about 40 percent of the medical student curriculum. “Preparing students for clinical care is a top priority of the School of Medicine,” Basaviah said. “We’ve kept a continued focus on clinical excellence with longitudinal mentorship that includes advancing communication and clinical skills as well as professionalism.”
A few of the new classes in the Discovery Curriculum began during the 2017-18 academic year. Now, the curriculum is fully implemented. It includes several restructured courses and some entirely new ones, along with an option to split the second year of medical school into two years to give students large blocks of free time for research during the second and third years of school.
Among the new courses is the Pharmacologic Treatment of Disease, led by Kobilka. His participation, not only as a designer of the curriculum but as one of its teachers, is notable. “Usually Nobel Prize winners are off doing other things and not teaching in medical schools,” Utz said. “But ours are here on campus. They’re vocal. They’re in front of the students and deeply involved.”
Time, and funding, for discovery
Not all students will choose to split their second-year coursework over two years. But those who do will have a variety of options for using the unscheduled time, and will pay the same tuition for five years that they would have for four.
Berg said that although some will choose to do research, many of the MD students he interviewed during the redesign efforts expressed a wish to take classes on the university’s main campus and possibly earn a master’s degree. Other students may opt to split the curriculum for other purposes — parenting a new baby, training for the Olympics, writing a novel or just slowing down the pace of learning. The advantage of the split curriculum is that students can start a research project during the spring or summer quarter of their first year and have sufficient time to continue it for the next two years. This type of extended scholarly experience had not been possible in the previous curriculum.
What we want our students to do is not to emulate us, but to eclipse us.
“We are luckily a medical school in the middle of a major university campus,” Gesundheit said. “The opportunities for dual training for interdisciplinary work are enormous.”
Opportunities for financial support are available to students who add a sixth year to earn a newly offered master’s degree in biomedical investigation. A new $2.5 million grant from the Burroughs Wellcome Fund and other funding sources could pay for that additional full year of research, as well as the two years of clinical rotations, for up to five students each year.
“The six years spent in completing the MD-MS training is shorter and less costly than the seven to eight years used to obtain the MD-PhD. Those two features increase the likelihood the student will elect an investigative career,” Berg said.
‘Feasible and worthwhile’
Students who began medical school in the fall of 2017 — and who are now starting their second year — are the first to have the option to split their second-year coursework into two years.
“I jumped at this opportunity,” said Joshua Guild, a second-year student who is researching how alveoli — the tiny air sacs that serve as the site of gas exchange in the lungs — are repaired by stem cells after injury. “The faculty here have done an amazing job of introducing additional flexibility in the curriculum to make an opportunity such as this both feasible and worthwhile.”
Guild’s classmate, William Shi, sees the chance to split his second year as a “sneak preview” into his future career as a physician-scientist. “I plan to spend this time conducting research, working to advocate for my classmates and patients, and taking care of my personal wellness,” he said.
Students who are the first to take part in the Discovery Curriculum know that their feedback will be an important part of refining and perfecting the new program. “I’m apprehensive about being the first cohort to split the curriculum,” said second-year student Areli Valencia, who is using the extra time to work toward a master’s in bioinformatics and continue his research. “But I’m also excited because I’m able to design my own path.”
For students, embarking on such a novel curriculum may feel like a big change, but innovation is precisely the point. “We’re persuading students to do the unusual, to be the pioneers,” Berg said. “We built it, now we want people to come and be a part of it.”
Students can still opt for the traditional four-year clinical MD degree at Stanford, but for those looking to change the face of medicine, from discovering new treatments to designing better health care systems, the Discovery Curriculum provides a foundation and pathway.
“What we want our students to do is not to emulate us,” Gesundheit said, “but to eclipse us. We want them to gain skills and leadership, knowledge — whatever they need — to become the academicians and the thought leaders, the change agents for the future.”
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