Overhauling Medical School

By Edward D. Miller, M.D. , and David Nichols, M.D.

Last Spring, the School of Medicine embarked on a two-year journey to re-examine its entire four-year curriculum. Executing the assignment is a committee led by Charles Wiener, a member of the Department of Medicine and a top teacher. Here, Dean Edward Miller and Vice Dean for Education David Nichols talk about the reasons behind the gigantic undertaking.

Q: You've commented that the Curriculum Reform Committee can "do truly historic work in defining the structure of medical education." Explain.

David Nichols: If you look at why Hopkins became the leader in medical education in the first place, it was because its founders had the vision to marry the leading scientific thought of their era -- organ-based pathophysiology -- with a structure and a full-time faculty that could apply that thought at the bedside. We have the same potential: to marry the organizing scientific principle of our era -- genetic medicine -- with expert faculty, facilities and technology that support that organizing principle. But curriculum has to fit into the picture, too. And the implications for education are much more complex than dealing with linear, organ-based pathophysiology. The genetic world is messy. Tens of thousands of genes and gene products interact with tens of thousands of environmental influences to lead to disease. Creating a curriculum out of this that students can learn and apply in four years is a big challenge.

Q: Are there any models out there?

DN: No, not like this, although many schools are re-examining their curricula. The Cleveland Clinic is looking at clinical investigators as the theme of their curriculum with a very close linkage to biomedical engineering. Stanford is looking at translational medicine and physician scientists as its cachet.

Q: But you're not going in that direction?

DN: No, because what they have targeted are physician products. Our view is to target a scientific principle.

Ed Miller: The ramifications of this could be far-reaching, because college students understand what makes particular medical schools successful, and they put their applications in accordingly. So the long-term question is, what kind of students will we attract?

DN: And how do we train them? We asked residents on the committee who went to school here to reflect on their experiences. They said Hopkins' greatest asset was its firm scientific grounding for medicine and later on for clinical care. Our goal is to hold on to that. But science is changing rapidly. Given our institutional legacy and students' attraction to the quality of our science, that should remain the core of our curriculum, rather than trying to produce physicians with a given career focus.

Q: You're convinced genetic medicine isn't a fad?

DN: The sequencing of the human genome will rank as one of the seminal scientific achievements. We're in a transition phase between the old, linear, organ-based physiology world and the new, messy, multidimensional genetic medicine world. The implications for medical care are just beginning to roll out.

EM: You are seeing early signs of that in the way we approach a disease like lymphoma. Lymphoma's genetic markers could impact both treatment and survival or length of life. It's just one more example that personalized medicine is closer to becoming a reality than ever before.

Q: How do you integrate interdisciplinary medicine into the curriculum?

DN: It's a challenge. The student is an undifferentiated learner who must come out of medical school appreciating the big picture, and who gets very distracted when overloaded with minutiae in one area. Yet what makes Hopkins attractive to prospective students is the fact that our faculty practice is at the frontier of medical and scientific knowledge. Increasingly, that means they are at the intersection of specialties. That's why multidisciplinary care and the multidisciplinary model are so important.

We need a balance. I would envision that during a surgery clerkship, for instance, faculty would demonstrate the boundaries between surgery, minimally invasive surgery and interventional radiology. Students would come to appreciate that what five years ago was a surgical procedure now is a minimally invasive procedure and may become a radiologic one. And we don't legislate to students the order of their clerkships. We give them freedom and tremendous latitude in choosing electives. This I hope will continue to give them access to the multidisciplinary cutting-edge world.

Q: What will be the most obvious differences for students?

DN: Students won't be learning just from the professor. They'll learn from one another, mimicking what happens at the bedside or at the bench, where everyone contributes and collaborates. Then, there's the whole role of technology in transmitting information. Since we opened the Office of Academic Computing, this has just taken off. We're ahead of other schools now. One of the growing pains we're dealing with in this out-of-the-classroom learning is figuring out our expectations for class attendance. With everything available on the Web, students can get much of the information they need without ever setting foot in a classroom. But the Web is a tool. It can't replace the interactive environment of the classroom.