WELL-ROUNDED: Students will see patients early on. Stanford University Medical Center

patients don’t usually walk into a doctor’s office and announce that they have a physiological problem that’s related to such and such a pathology or requires a particular pharmacological response.

“They say, ‘I can’t breathe,’ ” says physician Julie Parsonnet.

That reality is driving revisions to the curriculum at the Medical School that take effect this September. Instead of sitting in courses that are discipline-based, such as microbiology, first-year students will now learn by way of organ systems—six weeks on the cardiovascular system, then another six each on pulmonary, gastrointestinal, kidney, skin, etc. And the courses increasingly will be problem-oriented, Parsonnet says. “Instead of giving a lecture about neurological signaling and saying, ‘This is how two epileptic cells communicate with each other,’ we’ll be saying, ‘Okay, you have a patient who comes in with a twitching right arm and then loses consciousness. Let’s talk about everything surrounding that particular problem.’ ”

Parsonnet, the senior associate dean for medical education, has been the organizing force behind the new curriculum. As a specialist in infectious diseases, she is grounded in both basic and clinical sciences, and a plaque on her wall attests to her classroom skills—the Henry J. Kaiser Family Foundation Award for Excellence in Preclinical Teaching 2002

She says curriculum revision is not only the hot topic at medical schools nationwide, but it’s also a recurring theme in professional journals. Traditionally, medical schools have followed the four-year model of instruction that Abraham Flexner envisioned at the turn of the 20th century: two years of basic science followed by a two-year apprenticeship. In other words, students first “learn what the body is made of, what the parts are, what the names are and how they work together and communicate with each other,” says Parsonnet. And in the second two years of medical school, they apply that knowledge in clinical practice. Think of it as learning a language, she says. “You spend two years in Spanish classes, then two years trying to write a novel in Spanish.”

‘From the first day, they’ll be studying ethical and end-of-life issues.’

At a time when “everybody is trying to figure out how we address the huge amount of information that is required to be a good physician in just four years,” Parsonnet suggests that the Medical School is carving out a distinctive approach. Perhaps it’s because Stanford is one of the few medical schools in the country that is situated on a university’s main campus—incoming students will sign up for “scholarly tracks,” like undergraduates declaring their majors. The eight choices: bioethics and medical humanities, bioengineering, biomedical informatics, the molecular basis of medicine, immunology, community health and public service, women’s health, and health services research.

In addition to completing coursework, students also will come up with a research question or hypothesis. They’ll then go about answering the question either through the “scholar’s arm” (library research and literature surveys) or through the “original research arm,” whereby they’ll receive funding to spend a year investigating their hypothesis in the lab. “It’s not enough to just learn the language and be able to converse,” Parsonnet says. “We care that they learn something in depth.”

The 86 incoming first-year students also will spend eight hours each week in a new patient-care course. “From the first day, they’ll be studying ethical and end-of-life issues,” Parsonnet says. “They’ll learn cultural competence—how to communicate with patients who are Hispanic or Asian, heterosexual or homosexual. And they’ll learn about quality care—how to advocate for a patient who doesn’t have health insurance.”

The course also will look at the personal qualities that contribute to the making of an understanding doctor. “We need to try to learn how to teach the important empathetic art skills of medicine, when you have to see a patient every 15 minutes,” Parsonnet says. “We want our students to know how to talk and how to listen carefully. I don’t know how you learn empathy, but you can certainly learn how to communicate, and those skills have to be emphasized throughout four years.”

Revisions to the curriculum will take time, and courses will continue to evolve over the next four years. And there are continuing challenges. For example, how to teach anatomy and physiology when professors no longer specialize in those fields? “There are no people anymore who sit around sticking electrodes into kidneys, saying, ‘This is what happens to fluids going through the kidney,’ ” Parsonnet says. “But it’s at that level that physicians have to know what’s happening.”

Some hurdles may be cleared with the help of simulation technologies. “Should medical students’ first surgical experience be on a patient?” Parsonnet asks. “Or on a simulation, where they can learn how to make incisions and stitches and put in central and peripheral lines?” She points to the success of teaching aids such as 3-D imaging, virtual imaging and a device known as e-Pelvis (Farm Report, September/October 2002). “And our ‘standardized patients’ are unbelievable,” Parsonnet says, referring to the actors who “present” with imagined diseases to medical students. “We have a guy who does manic depressive illness, and—oh, my.”

One anecdote making the rounds of conferences these days goes something like this: “If you’ve seen one medical school curriculum, you’ve seen one medical school curriculum.” Schools may agree that changes are needed, but Parsonnet predicts that each will come up with a solution that meets its distinctive needs. For Stanford, it’s largely a matter of “facilitating what students want to do,” she says. “We have students interested in bioengineering and students interested in community service, and they tend to come here with more defined interests because they see the opportunities here.”

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