Last year, Dean Thomas Lawley went back to school. Accompanied by Jonas (“Jack”) Shulman (former long-time executive associate dean for medical education turned senior adviser to the dean for curriculum development), he visited some of the nation’s leading institutions. Why the return to the classroom? Lawley was studying medical education curricula, and these schools are in the process of reforming ones that have been in use since the early 1900s.
“Emory is a 20th-century teaching success story,” says Lawley, “but the 21st century is here. Warp-speed scientific advances are changing how medicine is practiced, and we must ask ourselves if we are adequately preparing our students for the incredible journey ahead.”
The timing for curriculum overhaul couldn’t be more perfect. At several critical junctures in its 150-year history, Emory has redefined itself to lead, avoiding the downside of venerability and of becoming hidebound in ways that brought past success. Now, with a long-awaited education building on the drawing board, new wallsare literally going up as old walls are figuratively being torn down.
The question now on the table is, What kind of physician or medical scientist does Emory want to produce for the new century? A new curriculum strategic planning committee, advised by Shulman and co-chaired by Stephen Warren, chair of human genetics, and infectious disease specialist Carlos Del Rio, is now seeking that answer.
Their charge is a bold one: Design a novel way of teaching medical students that reflects extraordinary advances taking place in science and meets the needs of an ever-changing health care environment. Rather than simply tweaking Emory’s current curriculum or replicating curricula under development at other schools across the country, the committee is to develop a curriculum to excite and inspire Emory’s own faculty and serve as a national model. Implementation and the specifics of how to pay for these innovations will be the job of others.
“Some things are a moral imperative, and preparing the best doctors in the best way is one of them,” says Lawley. “The school will find a way.”
Bricks and mortar for student-centered learning
Although the proposal from the planning committee isn’t due until August, some changes are self-evident, and the school is incorporating them into the new $55 million, 175,000-square-foot building, currently in the final planning stages.
Rather than “talking at” students in one huge auditorium, instructors will hold more small group sessions, such as the popular problem-based learning modules the school is already squeezing into borrowed classrooms. The building will include three 170-seat auditoriums, 18 small group rooms designed for 20 students each, and another four rooms designed for 40.
The first-year class in the new building will have up to 130 students, a 10% jump over current enrollment, with room left to add another 20 or more students to each class in the future. “Having room for growth is immensely liberating,” says Lawley, because admissions decisions in the past have been limited by how many students could be squeezed into the gross anatomy lab.
The building also will feature what the dean calls “the human space that enhances learning. We want students and faculty to walk into the first-floor lobby, with its soaring atrium and natural light, and immediately feel at home,” he says. The “nomads,” as current students call themselves, will no longer need to seek out spare couches at local coffee shops to study or squeeze into the basement in the Woodruff Health Sciences Center Administration Building (nicknamed “the tomb”). A student commons will be the first-ever designated gathering place for Emory medical students on campus that can accommodate a significant portion of an entire class at once. Spacious student lounges and quiet nooks and crannies will allow for a variety of study styles.
The building will be the university’s first entirely wireless facility. It will have coffee and sandwiches available on site, with a food venue for faculty, students, and visitors serving as a way to boost student-faculty interactions outside the classroom.
From day 1
When neuro-ophthalmology professor Nancy Newman lectures to first-year students, she has an unfair advantage. “The basic science faculty have to give them peas and carrots,” she says. “I’m the favorite uncle who arrives with candy.” The candy consists of patient cases, meant to illustrate the clinical relevance of what students are encountering in their basic science courses, and it’s so sweet that many in the class are convinced they want to be neuro-ophthalmologists—at least until they are given other clinically relevant material.
This approach is a small taste of what Lawley wants in huge servings in the revamped curriculum. The model of two years (more or less) of straight basic science, followed by two years of straight clinical science, is out. The immersion of students in clinical experience from day 1, with clinical medicine taught alongside basic science, is in. That means students can immediately begin honing essential skills, such as communicating with patients, that don’t require knowledge of the intricacies of basic science. It also means they can better appreciate the relevance of basic science to disease.
No one supports the combining of the basic sciences with patient care more than Warren, a basic scientist par excellence—the discoverer of the fragile X gene—who works side by side with clinicians every day. “With all the advances occurring in biomedical research, students simply have to become lifelong learners,” Warren says. “For example, one of the big shifts of medicine in the future will be a movement away from treating disease to preventing it, from physicians as firemen to physicians as fire rangers. The best way to prepare our students to understand the science of this different mindset is to pair clinicians with basic scientists and teach students the fundamentals of science within a clinical setting.”
For Del Rio, the separation of basic sciences and clinical care is also artificial. The advances in molecular diagnostic testing for infectious diseases or in drug discovery for HIV are perfect examples of how modern clinicians need to have a good understanding of basic sciences to provide excellent and up-to-date patient care, says Del Rio.
Fourth-year student Candace Smith-Teunis learned about lungs and other organs in bits and pieces throughout her first two years. “You don’t really get a sense of it all until you see a patient,” she says. She met her first patient with emphysema during her third year and saw how he struggled for breath, responded to medication, and turned to his doctors for help. “I loved all I was learning in the first two years, and I felt so well prepared for USMLE boards,” she says. “But seeing that patient really solidified my education. I wished I could have seen him earlier. I think the more the faculty can remind students of why they decided to come to medical school in the first place, the better our education will be.”
Human anatomy revisited
The painstaking dissection of a cadaver has long been a rite of passage in medical school. Once the only way to see inside the human body, human anatomy has changed little over the past century despite the explosion of sophisticated imaging technologies.
In keeping with a more clinically focused curriculum, the curriculum committee is discussing the advantages of spreading anatomy diffusely througout training rather than containing it in a first-year blitz, according to Warren and Del Rio. Perhaps students should wait to dissect the heart until they are studying heart disease or the lung until they need to understand the impact of lung anatomy on lung disease. Perhaps appropriate clinicians will enhance the experience by joining the anatomy professors in the dissection room.
While committee members agree that dissection will never go away, the revamped curriculum must take better advantage of the dramatic changes in imaging over the past decade. In the new building, a greatly enhanced dissection space with 26 tables, for six students at a table with computer monitors, will allow students to view MRIs and other images of what they are dissecting. Facilities for fresh tissue, in addition to embalmed cadavers, will give students more realistic experiences as well as support clinical faculty who prefer to practice new procedures on fresh tissue before performing the first ones on actual patients.
will set us apart
Patient simulation, already used widely for education in the new medical school facility at Grady and in the nursing school, is going to set us apart, says Lawley. Emory is a leader in this area with a well-established simulation training and robotics program in gastroenterology and general surgery.
A simulation laboratory suite in the new medical education building will allow faculty to create varied teaching situations using patient models. For example, students can conduct a patient history and examination in a fully-equipped exam room or face a critical patient situation in an emergency room setting. The scenarios resemble what happens when nervous students meet their first real patients—except these patients are actors trained to take on patient roles. In a nearby control room, faculty can observe and correct the student’s activities, captured on ceiling-mounted cameras.
Or the “patient” may be an electronic mannequin, increasingly sophisticated descendents of putty-colored Harvey, who tirelessly cranks out a variety of heart sounds until students are able to discern differences. Or the training may make use of virtual reality programs Emory physicians have created that allow physicians to thread a catheter through an artificial circulatory system and view angiograms of the patient’s heart for feedback on how well they are learning a complex endovascular procedure such as carotid stenting. The approach is still “see one, do one,” but thanks to growing simulation technology, students and physicians alike no longer have to perform their first complex procedure on an actual patient.
This electronic simulation technology also will prove invaluable for busy practicing physicians, many of whom use distance learning. It fits in well with the curriculum revision, which calls for Emory to ramp up its continuing medical education program.
No more one-size-fits-all
In the past, the lock-step rigidity of medical training limited opportunities for individualized experiences. By contrast, Emory’s new curriculum is likely to demonstrate unprecedented flexibility. Working with faculty from Emory College, the curriculum committee is considering a shift in some basic science requirements to undergraduate years. Such “advanced placement” options would buy time in medical school, allowing students to select more in-depth experiences similar to the research stints many Emory medical students now request in the window between their first and second years.
Lawley also would like to see an optional tuition-free year in the middle of medical school, so students could pause for an MPH or MBA. Or they could spend a year helping provide care in a developing nation or immersing themselves in a research program in basic science, clinical science, or the translational medicine that increasingly characterizes medical research.
Finally, the curriculum will take full advantage of the abundance of riches that makes Emory medicine unique: diverse clinical settings; strong colleagues in nursing, public health, business, law, and theology; one of the nation’s leading primate research centers; and close partnerships with the Centers for Disease Control and Prevention, The Carter Center, and other global institutions.
Gastroenterology chief Vincent Yang speaks for many of his colleagues when he says, “The same resources that make Emory known nationally for its clinical training—the wide diversity of diseases and of ethnic and social backgrounds seen in the various hospitals and clinics—are going to make it easy for Emory to become an education and research leader in the new genomic era. Tomorrow’s medicine is going to require basic sciences and clinical medicine working together, and we have a tremendous advantage over our peers.”
The people who will make it work
No one knows better than Lawley that such an ambitious new curriculum will require buy-in from a faculty already stretched by declining income margins and mounting paperwork. How teaching will be measured, protected, and rewarded is a hot topic on the medical campus these days. Along with concerns, however, is the faculty’s readiness and enthusiasm for the changes and excitement over what a new building will mean for teaching. Among the faculty, one of the largest in the country, are many well-known teachers as well as a great quantity of untapped talent and interest. For example, the medical school’s workshops on “learning to be a better teacher” draw 70 to 80 faculty each time they are offered.
For much of the school’s long history, patient care has received the most attention from administrators, out of necessity as much as love. About 20 years ago, the school began to launch its rocket in research, which has now reached an astonishing trajectory. Emory’s medical school now consistently ranks among the most rapidly rising of the top 25 schools in the country in terms of NIH research funding and received $275.8 million in fiscal year 2004. “Now, it is teaching’s turn to get the school’s full attention,” says Lawley.
How will the school pull it off? “We’re going to make a compelling case to our friends,” says Lawley. “To our alumni who know what their education has meant to their own success and who would like to see their alma mater become ever greater. To our patients who understand that the doctor who helped them was once a medical student and that the treatment they received was produced by basic and translational scientists trained in medical school. And to everyone who wants their grandchildren and great grandchildren to be treated by the most outstanding physicians possible.” He counts himself among that group and has joined the medical school’s 150 Society, made up of donors of $150,000 or more to the new building where those very physicians will be trained.
Let one of Emory’s soon-to-be-newest physicians have the last word. “I knew from the first day at Emory that the faculty didn’t just want to make me a good doctor,” says Smith-Teunis. “They also wanted me to be a human doctor, to keep that humanitarian part. They do it by the kind of people they surround you with, the role models, and by how much the administration cares about always making the school a better place.”
Sylvia Wrobel, former associate vice president of Health Sciences Communications at Emory, writes about science and medicine.
Copyright © Emory University, 2005. All Rights Reserved