New curriculum framework merges basic and clinical sciences

For the past century, medical education has followed the model proposed by Abraham Flexner early in the 20th century—a grounding in human biology and pathology followed by apprenticeships at the side of practicing physicians. In recent years, however, medical schools around the country, Yale among them, have sought to break away from that model.

“A lot is changing about the world that we live in, and we wanted to be sure that as a school we are staying at the cutting edge of those changes so that our students as they graduate are the best prepared they can be for the world they’re going to enter,” Richard Belitsky, M.D., deputy dean for education, Harold W. Jockers Associate Professor of Medical Education, and associate professor of psychiatry, told an audience of alumni at the School of Medicine’s 2012 reunion. “The goals of our new curriculum reflect the expectations of doctors that have emerged from the explosion in scientific knowledge and the revolution in the way health care is practiced,” Belitsky said.

“The future isn’t coming, the future is here,” he said.

In 2010 the medical school completed the Strategic Plan for Medical Education. Its two major recommendations are to build a new curriculum from the ground up and to encourage and reward excellence in teaching. Over the past two years, Belitsky said, a committee of faculty, students, and alumni began the curriculum rebuilding process by creating a new framework for medical education at Yale. But Belitsky assured alumni that the Yale system that they recall as “the most special part of their medical school education” will inform the new structure. The five guiding principles identified by the Strategic Planning Committee—integration; assessment and reflection; scholarship and creative thinking; educator development; and a learning environment that encourages self-direction and collaboration rather than competition—are an attempt to find a balance between tradition and the future, Belitsky said.

Increasing fiscal pressures make it challenging for faculty to participate in teaching, Belitsky acknowledged. So the Strategic Planning Committee developed two strategies to make it easier and more rewarding for faculty to teach: the creation of a Teaching and Learning Center; and the elevation of the status of teaching by having it count more toward reappointment and promotion. The teaching center’s three main objectives are: educator development, including support for implementing innovative curricula; assessment of student learning, the quality of teaching, and the effectiveness of curricular changes; and expertise in technology.

Among the eight overarching goals of the new curriculum, Belitsky highlighted health promotion and disease prevention as well as responsibility to society, including cultural competency and fiscal responsibility, as increasingly important expectations of physicians. These new foci are balanced by the more traditional goals of the Yale system: the creation and dissemination of knowledge, and understanding medicine from a scientific-minded point of view.

The new design that has emerged departs from the traditional model of medical education—two years of basic science followed by two years of clinical clerkships and electives—by emphasizing the integration of clinical and basic sciences. The thinking is that the basic sciences will make more sense to students—and stick with them—if taught in the context of patient care. Under the new framework, much of the first year and a half will include a concentration in basic and clinical sciences; but it will begin with the Hospital Immersion Program, a four-day introduction to clinical care that debuted in 2010, followed by a longitudinal clinical experience in which students spend a half day each week in a clinical setting.

“One important way to start understanding the seriousness of what we do is to have them put on a white coat at least once a week, show up in a place where they see real medicine practiced, where they see real people with real problems, and doctors with enormous responsibility,” Belitsky said.

The students would still have two free afternoons each week, and carving out even more free time is an important element of the new design. Basic science studies would end six months earlier, in December of the second year. Clinical clerkships would begin in January rather than June of the second year, and each clerkship would begin with a “precede” in which students revisit basic, social, and clinical science concepts related to that clerkship. During clinical immersion, there will be “bursts,” additional opportunities for teaching those concepts. The last year and a half of medical school will offer students more flexibility to pursue sub-internships, electives, and research.

Overseeing this effort is a Curriculum Steering Committee composed of faculty, alumni, senior administration, professional educators, and students. The committee has held fireside chats to bring together faculty and students for discussion about the content of the new curriculum.

Belitsky invited alumni to visit the new curriculum rebuild website, where they can participate in discussions about curricular reform and stay informed about its progress. Alumni asked whether assessing the curricular changes will produce physicians who deliver better care. Belitsky said they are trying to develop better methods for evaluating the students—not just through paper tests and board examinations but also through direct observation and mentorship. The school is strongly committed to developing metrics to measure the effectiveness of the new curriculum itself.

“Yes, this is hard; yes, this is messy, but that doesn’t mean we shouldn’t do it,” Belitsky said. He estimates that it will be about two years before the new curriculum is implemented.

Belitsky will be sharing more information about the curriculum in an upcoming message to alumni.