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New ways of teaching, new ways of learning

As the century-old model of medical education shows its age, the School of Medicine rebuilds its curriculum.

Photo by Cushing/Whitney Medical Library
In this photo, taken around 1900, the legendary surgeon and medical educator William Carmalt (standing at left) lectures at the medical school, then located on York Street. Ten years later, Abraham Flexner’s model of medical education—training in basic science followed by training in the hospital—would become the norm. Now medical educators are revising the model to merge science and clinical education.

Two years of science, two years on the wards: That familiar structure of the American medical curriculum took shape over a century ago. But it’s showing its age. Medicine is changing faster than that structure can keep up.

So at Yale, the medical school’s legacy curriculum is now no more. In a process that started in 2008, hundreds of faculty, students, and alumni dismantled the old and built a brand-new curriculum. It launched last fall, with first- and third-year medical students becoming the first to experience the new coursework and clerkships.

“The way we practice medicine has changed drastically. People’s expectations of doctors are changing, too,” says Richard Belitsky, M.D., HS ’82, FW ’83, the Harold W. Jockers Associate Professor of Medical Education, associate professor of psychiatry, and deputy dean for education. “We took a fresh look at everything we’re teaching, which included what we were teaching, when and where in the curriculum we were teaching it, and how we were teaching it.”

Belitsky called the rebuild process a “steep uphill climb” at an internal medicine grand rounds in the spring of 2015, as the school prepared to launch the new curriculum. “But I’m here to reassure you that the view from the top is spectacular,” he told the assembled faculty.

It’s quite a vista—one that has changed dramatically since 1910, when the two-and-two curricular structure appeared in Abraham Flexner’s critical report on then-shoddy American standards of medical education. The Flexner report transformed those standards, which have remained high to this day. But arguably, medical practice is no longer the same straightforward exercise in scientific diagnosis and treatment that it was even 30 years ago. Physicians must now think of the whole patient, her culture and socioeconomic setting, the medical system, and societal dynamics that lead to disparities. Disease prevention is gaining great importance. Electronic medical records and the bottom line haunt practice; genomics offers unheard-of insights; simulation technology and digital devices change the learning process. Teamwork is supplanting the old doc-on-top hierarchy.

There’s only so much of this you can tack on to a traditional curriculum. So Yale’s starts fresh.

A break with the past

Rather than the traditional year of basic science followed by a year of clinical science, the new curriculum weaves them together. Now first- and second-years take eight integrated courses over a year and a half. Each course goes broad as well as deep on themes like “cell energy,” “plasticity and disease,” and “the reproductive years and middle age.” The last course, for instance, includes elements of embryology, pathology, cell biology, epidemiology, and pathophysiology of both the female and male urogenital systems. New subject matter is also appearing, including information on aging.

That first year and a half also includes longer courses in professional responsibility and scientific inquiry as well as clinical experience: students see patients in “pre-clerkships” throughout the first 18 months of school.

Whereas students traditionally began formal clerkships on July 1 of the third year, they’ll now take an earlier jump to the wards in January of the second year. (How will that change affect the second-year students’ annual stage-and-video spoof of faculty, the Second-Year Show? Read on.) Earlier clinical experiences offer several advantages, Belitsky says, including motivating students, offering context for what they’re learning, and providing a longitudinal view of care.

The clerkships themselves have changed. Rather than one- or two-month rotations, students now enter 12-week clerkships that combine specialties with similar approaches to the patient, like internal medicine and neurology. According to Michael L. Schwartz, Ph.D., associate dean for curriculum, attendings in one specialty are now taking the initiative to point out connections to the other: “There’s a change in the culture of the clerkship to think about this as a shared enterprise,” Schwartz says.

“In the past, there may have been important aspects of communication with patients that were taught in the psychiatry clerkship that students should be aware of and practicing in all clerkships,” Schwartz says. “We’ve cherry-picked those things that we think are useful for all the clerkships and put them into these common precedes.”

Students wrap up rotations in December of the third year. That leaves an unprecedented 17 months of time for research and thesis writing, electives and subinternships, and the boards. Under the old curriculum, time for these activities had been shrinking: In recent years, 60 to 70 percent of students have taken the optional fifth year, according to Belitsky, some because they felt they didn’t have time to finish in four. The new schedule may allow more students to graduate in four years.

The new curriculum also focuses on teaching. Faculty development is a priority, as are new, more transparent standards for faculty and students to offer each other feedback. Through it all, administrators will measure student and instructor performance and keep tweaking the new curriculum.

Yale not alone in a rebuilt curriculum

Yale is far from the only medical school rethinking its approach. In fact, as of the 2012-2013 academic year—the most recent for which data are available—127 of 136 U.S. medical schools responding to a survey by the Liaison Committee on Medical Education were planning, were amidst, or had just completed a curriculum change. (There were 141 accredited M.D.-granting medical schools in the United States that autumn.) The trend is a response to numerous calls for reform beginning in the early 2000s by major groups like the American Medical Association.

At Yale, the process began in the autumn of 2008, when Dean Robert J. Alpern, M.D., Ensign Professor of Medicine, asked Belitsky and other faculty to begin planning for change. The Strategic Planning Committee for Medical Education was born. Two years later, the committee issued a formal report calling on the school to reform the curriculum and to elevate the status of teaching at Yale. Four previous strategic-planning efforts in 20 years had identified those needs, the report pointed out, but the school had implemented them at best only partially.

This time, the ball kept rolling. In 2011, the outlines of a new curriculum appeared in the report of the Curriculum Design Committee. The next four years were spent planning the details, and by 2015, the committee was unveiling the new curriculum.

The process was painstaking. Formal principles and overarching goals guided scores of discussions among faculty who formerly had taught independently of one another. Now, they sifted through the content of nearly 30 courses and modules “with a fresh set of eyes,” Belitsky recalls. Numerous committees combed Excel spreadsheets, adding new content, figuring out when to introduce each topic, deciding what should be taught more than once and what was redundant. This process amounted to centralized coordination, which a new accreditation standard calls upon medical schools to put in place. But it’s much harder than letting departments teach independently.

Schwartz says it was a “healthy discussion, with some people seeing that what was already being done was adequate and appropriate, and others pushing for change in some areas. … You might expect those would be really contentious and laden with potential problems, but it was surprising how collaborative it was.”

According to Lisa P. Howley, Ph.D., senior director of educational affairs of the Association of American Medical Colleges, these changes mark a larger shift away from an older so-called process orientation of medical education to a competency-based educational program. These aren’t retrofits; they’re overhauls.

“Periodically, medical schools will revise, refresh, revamp their curriculum,” Howley says. “But what we’re seeing recently is that those efforts are much more substantive or significant with regard to changing not just content and experiences, but actually changing the structure of the curriculum. Schools are moving away from ‘What are we teaching and for how long and in what order?’ to an outcomes focus, so the question becomes ‘What are the actual competencies that we expect from our graduates?’,” Howley says. “The way we deliver instruction is changing.”

Howley sees a lot of schools integrating basic and clinical sciences in the preclinical years. Many besides Yale are changing clinical training, too. At 12 weeks, Yale’s new combined clerkships are substantially longer than the traditional one- to two-month kind. Some schools are going even further, implementing longitudinal clerkships that combine several disciplines for a six-month or longer period. Yale’s clerkship innovation may be that it pairs psychiatry with primary care, recognizing that those disciplines take very similar approaches to the patient. Howley and Belitsky say they don’t know of other schools that have put those two specialties together.

The Yale system stands

Despite all the changes, the Yale system remains intact. Changing the thesis requirement, Belitsky says, was never on the table. Emphasis on flexibility and student choice hasn’t changed, either. Optional self-assessments will continue to precede mandatory qualifiers in the preclinical years. (The clerkships’ old rating system is under scrutiny for a possible update.)

On the other hand: nudged aside by clerkships, the Second-Year Show is no more. But don’t panic. It’ll become the Fourth-Year Show—again, since the first student show, in 1949, was written and performed by fourth-years. (The second-years took over in the 1960s.) Schwartz points out that the curricular changes will infuse much-needed variety into the show: “They’ll have four years of faculty and staff to spoof as opposed to only two.”

Those instructors will likely take it in good spirits. There’s a sense of new energy at the school as the curriculum rolls out and as faculty and students try on new ways to teach and to learn together.

“It’s been remarkable how supportive the faculty have been in taking on these new roles,” Schwartz says. “There was a point where I think the energy in the process shifted from ‘Oh, my gosh, this is really hard,’ to ‘You know, this is exciting.’ ”