Hazards of Change

Rolling out a new curriculum could cause some uncomfortable moments.

By Dean/CEO Edward D. Miller, M.D.

I’ve been mulling over a crucial question: What should a 21st-century medical school education look like?

Barton Childs, the pediatrician who 50 years ago helped pioneer the whole field of medical genetics here, once commented that “it’s easier to move a graveyard than to bring revisions to medical thinking.” I wouldn’t go that far, but as we get ready to introduce a new medical school curriculum called “Genes to Society,” it’s clear that a lot rides on the answer to my question.

The fact is, a curriculum redesign as dramatic as ours can’t help but lead to changes in how physicians are trained and diseases are treated. We’ve created a revolution of sorts—and revolutions hold the potential for unintended consequences. Hopkins learned that a century ago when it became the first U.S. medical school to educate future M.D.’s by blending laboratory studies of disease with clinical training. That departure altered the underpinnings of medical education. It also sparked huge resistance among traditionalists. Our current reforms are bound to do the same.

But it’s clear that change must take place. Three years ago, Vice Dean for Education David Nichols and I began a series of soul-searching conversations to review the events that dictated reform. Chief among these was the sequencing of the human genome. That one step forward—with its accompanying potential for personalized, “molecular” medicine—demanded that physicians begin thinking differently about their role in patient care.

Simply put, our medical students could no longer regard the human body as a biological machine in which physicians act as mechanics when parts break down. Rather, they would have to learn a logic of health and disease that takes into account complex interrelationships among genes, along with each person’s particular protein profile, environmental experiences and exposures.

Out of Dave’s and my talks emerged a commitment to make serious modifications to the Hopkins education model—largely unchanged since the early days of medicine here. Dave conducted a review and concluded that just a decade from now, instead of relying only on episodic, reactive treatments for disease, physicians would likely be able to devise predictive, lifetime health-management plans based on each patient’s risks. And while doctors would continue to use their knowledge about disease patterns, they would understand that individual variation is the key to health.

Now, after three years of input from our faculty, we are ready to implement a medical curriculum that incorporates those new aspects of medicine. We also are ready to deal with the  risks of curriculum reform—the unintended consequences and uncomfortable moments—that such changes can inspire. Timing will be everything. We stand on extraordinary academic foundations at Hopkins, and we cannot abandon those underpinnings. Yet traditional expertise could  rapidly become obsolete. And so, we walk a fine line: We cannot introduce new approaches too late—or too soon. Nor can we move too fast or too slowly.

Finally, we know that our reforms may not mesh with the 128 detailed standards set by the Liaison Committee on Medical Education, which accredits American medical schools. Even when we have been thoughtful, or brilliant with our modifications, we could face difficulty in embracing standards  not like other schools’.

Uniformity of standards has its place, but we believe that homogenization doesn’t work for medical schools. One of the things that keeps Dave Nichols and me up at night is the realization that accrediting organizations might not recognize that one size doesn’t fit all. Variation is not only the foundation of the new biomedicine but a necessary approach to medical education.

When I attended the University of Rochester School of Medicine and Dentistry, we were told the school sought to train teachers of tomorrow’s doctors. Hopkins, Harvard, Stanford and Columbia, meanwhile, have carved out roles as educators of clinician-scientists. Our students choose us because they hope to learn bench-to-bedside treatment for complex diseases rather than serving as family practitioners in community hospitals. Others of America’s 125 medical schools, however, have chosen that mission.

What should a 21st-century medical school education look like? The answer to that question, I think, rests with diversity and flexibility. Medical schools must ensure that students are proficient in the fundamentals while recognizing that health care is changing rapidly and we all have different training goals.

I’ll keep you informed as we roll out our curriculum. Meanwhile, I welcome your thoughts and comments. This much I can tell you: Hopkins is ready for the challenge. We’ve reached a pivotal moment in American medicine. And we are still where we should be—on the cutting edge.