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Deconstructing education

The breathtaking discoveries of the last three decades and rapid change across all of medicine have called traditional models of medical education into question. At Yale, the debate is in full swing.

The school was at a crossroad. Medical knowledge was growing at a startling pace. Wondrous new cures were in the making, and scientists were beginning to understand the complex workings of disease at a level of detail that was unprecedented. As a result, medical students had to master a stupefying mass of knowledge. A new way of teaching was needed.

The time was 1922. The dean was Milton Winternitz, M.D. His solution was the Yale System of medical education. Eight decades later, students and faculty face similar problems—masses of new findings about disease and treatments and overwhelming amounts of knowledge to be learned, compounded by the escalating speed of discovery and communications. Add to the mix changes in the economics of medicine and delivery of care, and what you have is a medical school at a crossroad, once again contemplating precisely what, and how, to teach.

“Yale medical students love the Yale School of Medicine,” says immunologist Charles A. Janeway, M.D., “but they don’t love everything about a Yale medical education.” What’s not to love? Of the 3,500 applicants seeking a place in next year’s entering class, only 105 will be given the opportunity to study medicine here with more than 1,000 of the world’s most highly regarded clinicians and basic scientists. The school’s pioneering laboratories churn out new discoveries about life at the molecular level at an astonishing rate. Articles by faculty appear almost daily in prestigious medical and scientific journals. Students learn from physicians at one of the nation’s top teaching hospitals. During the fall term this academic year, the school saw guest lectures by two Nobel laureates, one of the leading lights in gene therapy, and a slew of distinguished visitors from around the world.

Then there is the Yale System of medical education, a unique approach to learning that remains strong after three-quarters of a century. Its elements—time for independent study, no grades or class rankings, treatment of students as mature adults responsible for their education—all add up to a unique atmosphere. For one thing, says fourth-year student Evelyn Duvivier, “We’re not competing against one another. This is an environment where the focus is on learning. Students are driven by knowledge, not by grades.”

With all this, in the view of many students and faculty, it’s still time for a change. Janeway, a professor of immunobiology and biology, is in a position to know. Since early last year, he and Ralph I. Horwitz, M.D., chair of the Department of Internal Medicine, have led an education committee convened by Dean David A. Kessler, M.D., with an eye to improving the curriculum as well as the school’s more general approach to education. Not all of the committee’s recommendations are new. Each decade since the 1920s, previous committees have made proposals on various facets of the educational experience without always seeing them implemented. But there is a sense this time that things are different.

“There are both internal and external forces demanding a revision of the curriculum,” says Ashgar Rastegar, M.D., a professor of medicine and member of the education committee. “There has been a major revolution in science. There has been a major revolution in the delivery of care. Society is demanding that we look at whether we are training the right kind of physicians. Students and faculty are asking, ’Is this the best way to teach and to train physicians?’ ”

“There is change occurring everywhere we look,” says committee co-chair Horwitz, “not only in the health care system in which we practice, but in the medical schools that are our peers.”

The committee’s charge, in the words of Kessler, was to inquire into “what we teach and how we teach.” The consensus of its members, after meetings with course directors, faculty members and students, and reviews of curricula at other medical schools, was that medical education at Yale is very good but could be better. As its guiding principles, the committee proposes to enhance the educational environment, refocus the educational process, strengthen the Yale System, enrich the curriculum, redesign administrative oversight and implement new programs in medical informatics. Last fall it presented a list of initial findings to department chairs and the faculty. As Yale Medicine went to press, school-wide discussion of the issues raised by the committees was beginning in earnest. Kessler, who has not endorsed any specifics of the plan so far but supports the direction of the committee, has held several meetings on the topic with the department chairs. A series of “town meetings” with faculty and students, begun in January, was to continue through the spring.

“Yale School of Medicine,” says Horwitz, “is trying to find a way, given the extraordinary changes taking place in medicine, to renew the Yale System’s fundamental principles — independence, self-study, understanding the scientific method and applying science-based medicine to clinical problems.” When Winternitz introduced the Yale System in the 1920s, he eliminated 1,200 hours of instruction from the schedule. The crushing burden of the curriculum, he felt, stifled independent study, contemplation and initiative. Advocates of the Yale System felt that absorbing a mass of facts was less important than a grounding in fundamental principles, methods of investigation and the scientific method.

Now the education committee’s goals are to integrate course materials across departmental boundaries, implement more case-based teaching, correlate the basic and clinical sciences, allow students more structured time to conduct original research toward their thesis requirement, cut down on class hours, and restructure the program so that clinical studies begin on the first day of medical school and basic sciences continue to the last day. Clinical exposure in the first two years, the committee found, is insufficient and haphazard, and the third-year clerkships need a thorough review. Some peer institutions have already tackled these issues, Janeway and Horwitz note, and are moving toward a system of problem-based learning and small-group teaching, rather than large lectures.

The committee also addressed the prevailing notion among the faculty that the road to recognition, advancement and tenure lies not in teaching, but in research and clinical work. “Nothing,” says Janeway, “undermines the success of medical education more than the perception that teaching is secondary.”

In presenting their findings, Janeway and Horwitz made it clear they’re under no illusions about the complexity of their task. Making changes means placing authority for curriculum in the hands of the deputy dean for education, who, under their proposal, would be armed with a sizeable budget. The new deputy dean, Herbert S. Chase, M.D., was chosen in part because of his experience in curriculum design. At the Columbia University College of Physicians and Surgeons, where he has taught for 22 years, he created courses that integrate basic and clinical sciences. He’s also very interested in applying information technology to medicine, to ensure that physicians have the best possible data when they’re treating patients. Chase, currently a professor of clinical medicine at Columbia, will officially begin his duties at Yale in July. One of his first, and most important, charges is to oversee the curriculum revision process. “We live in an era in which we can easily discuss the molecular basis and the molecular treatment of very common diseases,” says Chase. “They really go hand in hand. There’s nothing preventing us from having a much more fluid curriculum where we have basic science and clinical science interwoven throughout the four years.”

Past efforts at curriculum reform have generally stumbled over departmental turf battles. “The curriculum too often finds itself responding to the needs of the department rather than what might be pedagogically sound,” says Robert H. Gifford, M.D., HS ’67, who served as the school’s first deputy dean for education until his retirement in December. “It has been very difficult to convince basic science departments to reduce class hours, to introduce interdepartmental teaching, to introduce case-based teaching and to form partnerships with clinical faculty.”

Emile L. Boulpaep, M.D., professor of cellular and molecular physiology and the department’s interim chair, headed a curriculum committee a decade ago but found departmental and faculty resistance to reform too strong to overcome. “It touches on very special issues of identity,” he says. Frustrated in his attempts to forge wider interdepartmental integration and coordination, he and colleague James D. Jamieson, M.D., Ph.D., head of cell biology courses, did it themselves on a smaller scale. Physiology and cell biology are still separate courses, but lectures and classes are scheduled to complement, rather than repeat, each other. “We are here to make the optimal learning process for the students,” says Boulpaep. “If that learning process requires working together and integrating two fields of science and the student will reap the benefit of it, there is no reason we shouldn’t do it.”

There are other examples of integration. Second-year students take a course called “Mechanisms of Disease,” which takes a system- and organ-based approach to material traditionally taught in pathology, pharmacology, laboratory medicine and other disciplines. But some faculty would like to see much more collaboration. Jamieson, who won the 1999 Bohmfalk Prize for excellence in basic science teaching, believes the basic core of what physicians must know hasn’t changed. “They need to have a solid grounding in cell biology, molecular genetics, pharmacology, physiology, biochemistry and pathology. You can’t be a doctor without those things,” he says before adding: “There is a lot of stuff that could be cut out if courses were better scheduled or better integrated.” Jamieson also stressed that as the number of students in the M.D./Ph.D. program increases from about 10 percent of the class to 15 percent, the school must continue to emphasize a solid foundation in the basic sciences that will be required of physician-scientists.

In the classrooms along Cedar Street, faculty members employ a number of teaching approaches. Some classes follow a traditional undergraduate model of a large lecture followed by small-group meetings with a graduate student. Boulpaep prefers the small groups of about 10 students he convenes every Thursday morning for lessons in physiology. He uses the Socratic method, tossing out questions, then questioning the answers. “Why would the blood not be saturated?” Boulpaep asked of a case of cystic fibrosis. “It’s not getting oxygen,” a student responded. “Why is it not getting oxygen?” Boulpaep asked, prodding the students.

Across campus at the Yale Health Plan, medical student Duvivier, then in her third year, worked one-on-one with a physician-supervisor in internal medicine as part of her clinical clerkship. Typically, she would interview patients on her own, then present her findings and diagnosis to her supervisor. One case involved a 63-year-old police officer with a cough. Duvivier reported to David Smith, M.D., her suspicion that the officer was reacting to the dander of a cat he’d acquired a month earlier. “I think it is very hard for someone to acknowledge that their symptoms might be caused by something they treasure,” Duvivier said.

“It sounds very classic, doesn’t it?” Smith asked. “I think you did a very good presentation formulation. Do you think we need to do any further work-up for the cough, a chest X-ray?” Smith wanted to rule out tuberculosis, a risk of the officer’s job. “You’re right,” Duvivier said. “A PPD skin test and a chest X-ray would rule that in or out.”

When it works, education in the clinical years is satisfying to those involved. “I feel that my opinion and my diagnosis are taken very seriously,” Duvivier says. “I’m still a student, but I am treated almost as a colleague.”

That said, students and faculty have their gripes. Faculty complain about students who don’t show up for lectures and small-group seminars. Students cite examples of attendings who miss rounds. And there’s the evaluation system during the clinical years. “It is not based on anything scientific,” says Janeway. “It is based on residents liking you or not liking you.”

Medical education throughout the country has its roots in the 1910 Flexner Report. Concerned about the rise of proprietary schools that were thought to be little more than diploma mills, the American Medical Association commissioned a study by Abraham Flexner, a noted education reformer. He took as his model Johns Hopkins in Baltimore, where the medical school was affiliated with a university and had a strong research component. Since then medical schools have, by and large, followed the same pattern—two years of basic sciences followed by two years of clinical studies. After the Flexner Report, the next big change in Yale medical education came in 1922, when Winternitz and his faculty began to implement the Yale System. Faculty kept an eye on the system, monitoring it through the 1930s and 1940s. Despite some tinkering with its elements, it has survived largely intact over the years.

“What is good about the Yale System is the collegial atmosphere,” says David Spiegel, an M.D./Ph.D. candidate and one of three student members of the education committee, “and the genuine proximity students have to faculty, especially in the basic science years.” Says second-year student and committee member Rebekah Gross, “It is much more humane in the sense that if you have a personal problem or something going on with your family and you can’t learn something this week, then you can learn it next week. That is important in helping you stay focused.”

Within weeks of donning their white coats, first-year students get a glimpse of how things could improve. “The education we get is great,” says Spiegel, “but it really could be made a lot more pleasant and a lot better if there were more coordination among departments and faculty members.” During his first year of medical school four years ago, Spiegel says, students faced a parade of basic science lectures that often were redundant. The result? Overlap in material, boredom on the part of students and frustration on the part of faculty who wondered why attendance was low.

How do students handle the sometimes overwhelming volume of information they must master? “You know what you should be reading and you just can’t do it,” says Gross. “So you pick and choose. The two words you hear most here are ‘high-yield.’ ” That’s student jargon for quality information that covers a variety of situations. The highest praise students accord professors is to say their lectures are “high-yield.” Said one second-year student in praise of a lecturer in microbiology, “She tells you what you need to know.”

More integrated courses and more correlation of the basic sciences to clinical practice would ease the absorption of all that material, according to some faculty. “You don’t learn medicine by reading a textbook,” says Barry J. Wu, M.D., an assistant clinical professor of medicine and recipient of the 1999 Blake Award and the 1999 Bohmfalk Prize for excellence in clinical teaching. “You learn by seeing a patient with a particular disease and going to the textbook and reading about it. Then you have a connection in your brain.” Correlation of the basic to the clinical sciences is one of the goals of the curriculum review. It’s also the impetus behind starting clinical sciences early and continuing basic sciences until the end of the four-year program.

While all involved in teaching support the goal of improving the framework for education, the debate over how to do that is just beginning. “There’s a concern,” says Jon Morrow, M.D., Ph.D., chair of the Department of Pathology, “that the time for basic science is contracting at the same time that the knowledge base is exploding. One could argue that it would be better to go in the opposite direction and increase the hours for basic science.” Chase notes that although time allotted to basic science might be reduced in the first two years, students will return to those subjects during their clinical years. “Some basic science topics will be a great deal more compelling when taught later on in the curriculum,” Chase says.

That Yale’s medical curriculum needs some revision is no blemish on the way the school teaches physicians. As Dean Vernon W. Lippard, M.D., noted in 1954, “No educational program worth its salt ever has or ever will be in final form. To be effective, it must be subjected to constant evaluation and improvement.” The “New Curriculum” that emerged 14 years later included features current proponents of revision would recognize—reduction in basic science class hours, early introduction of students to clinical medicine, study of basic science after clinical clerkships and an extended outpatient clinical experience.

As the school stands at a crossroad, it has embarked on a dialogue about how and what to teach doctors. Over the winter, the education committee launched its series of “town meetings” to open discussion to a spectrum of stakeholders at the medical school-faculty, staff and students. At the first of these meetings in January, Horwitz outlined different scenarios for reconfiguring the curriculum. The discussion is expected to last for some time. “Our strategy from the very beginning,” says Kessler, “was to have this committee be a several-year effort.” The committee’s proposals, Janeway notes, are designed to focus the conversation that will follow. “We need to have the whole school come together over this,” he says. YM