By Christopher Guadagnino, Ph.D.

Published October 1997

• React to this article in the Discussion Forum.

Gail Morrison, M.D., is Vice Dean of Education, University of Pennsylvania School of Medicine, Office of Academic Programs, and chief architect of Penn’s newly designed Curriculum 2000.

PND: What specific rationale prompted the redesign of the medical school curriculum?

GM: There has been a major shift of patient care away from the acute care center more toward the outpatient ambulatory office center. What we are seeing in the hospital is primarily very sick individuals with very complex medical problems or people who come in for short procedures. Managed care is making us shift our focus away from curative medicine to preventive medicine. Medical education, which has revolved totally around acute care settings and curing patients is now shifting toward preventing disease and care of patients in ambulatory and outpatient environments. That meant we had to relook totally at both what and how we were teaching students in order to prepare them to be that kind of physician.

PND: How does the curriculum integrate material in a new way?

GM: We have moved away from courses and into an interdisciplinary approach, bringing all the individual disciplines to the table in a room, making them develop the systems of the disease. For the cardiovascular system, as an example, you will start learning about the anatomy of the heart and then move into histology, then normal physiology, pathophysiology, specific drugs that affect pathophysiology, the infectious disease processes that can occur, the immunology in cancer. These are now horizontal themes that run through every single organ system. Following that, in the afternoon, you will see patients with specific diseases that you just heard about. You will see chest x-rays, you will see angiograms, you will have patients and families come in to talk about what it is like to be sick with heart disease, the impact it has on their lives, the cost to the public and to society related to doing a heart transplant, bioethical issues of who should get a heart transplant and who should not. It’s not a separate course on bioethics, on epidemiology, on microbiology, on infectious diseases. To make this a four year continuum, students would not only learn the underpinning of science, but also the clinical relevance simultaneously. There is material that threads through the whole four years of medical school around three themes: the science of medicine, art and technology of medicine, and professionalism and humanism. These are issues that have been touched on in medical school briefly, but, when you emphasize acute care medicine, had never been the focus.

PND: How have the instructional practices changed?

GM: The instructors came up with the content of what they felt was important, the knowledge and skill that they wanted the students to come away with. We wanted to move away from sitting students in a classroom—no more than, say, two hours a day in a lecture room format, and the remaining time in other educational formats. We brought in new multi-headed microscopes with video cameras and screens to have students work in groups of four to do histology, pathology and microbiology working together in teams. We have more small group sessions, case discussions, panels, computer-assisted learning. We’ve come up with a virtual classroom in which we videotape every lecture that is done, and within 24 hours is up on the Web for the students with all the slides digitalized, so the students can go back for review on any computer at the medical center or at home. We are trying to make education available to them when they need it in various modes, depending on how students need to learn.

PND: What response have you gotten so far from faculty?

GM: We started August 15th. Initially, there was hesitation. There was concern because we didn’t have a model which proved this would be better. We had piloted some programs in the previous five or six years of medical school in which we’ve had some interdisciplinary teaching. I started getting e-mail from faculty and they’ve started coming into my office within the first couple of weeks. They are so enthused. What they said was, "I cannot believe that it could work so well." It opened up enormous dialogue between faculty who had never really talked together, never truly understood what one department or course was doing related to another. We’ve forced them in some ways to begin to work together. When there’s a problem they now call each another directly.

PND: Why was this curriculum redesign implemented in its entirety without being more thoroughly piloted?

GM: This modular interdisciplinary integrated approach was so different than what we were presently doing that we had to make a decision that it was go or no-go. It was impossible to have two tracks of students, as many schools have done. This just scrambled everything that we did and totally took it out of sequence. We weren’t totally unsure of our result, because we have had several segments of the curriculum over the last five to ten years that has been either coordinated or—in the neurosciences—very integrated. We did neurosciences along with neurology, psychiatry and behavioral sciences all together in one block. When we looked at evaluations each year, it was very obvious that the more we coordinated, integrated and put in clinical materials, the more the students said, "This was good, this made sense, we understand why we’re learning the material and we can understand why it’s important."

PND: How is student progress assessed?

GM: The first four months of our curriculum—the basic core principles—are going to be pass/fail. All of the course directors from each discipline will meet as a team and go over every student who has come through those four months to make an assessment of whether that student should move on to the next segment. For the next twelve months, the integrative organ system segment, we do move into a grading system of honors, high pass, pass and fail. But you will get graded across the whole organ system, not for a course in pharmacology, or mechanisms of infection, or microbiology. You get graded for the cardiovascular block, the pulmonary block, the gastrointestinal and nutritional block.

PND: Although some students have received this redesign enthusiastically, others have expressed concern that it might hurt those who don’t have strong science background. What is your view?

GM: The reason we designed the curriculum in this modular approach is that we’re hoping within the first four months that everybody will be on equal footing at the end of December. To help the student who may not have had as much basic science, in addition to the actual coursework that is given to them, we have optional tutorials. There’s about 25 to 35 students out of a class of 150 that are tending to go to those tutorials.

PND: How do you plan to assess the redesign?

GM: We have a system for the students to evaluate what they’re learning, for faculty to evaluate how they feel the students are learning. Students will be taking all the normal standardized tests—national boards, clinical rotation performance. We’ll be monitoring how they’re doing relative to other classes that have come through the traditional curriculum.

PND: Does the content redesign place less emphasis on basic science and more on such things as preventive alternative medicine and humanities?

GM: It turns out that you probably get more basic science into the curriculum through the whole four years of medical school than previously when to tried to shove it all in in the first year and a half. We will be making sure that basic science is emphasized throughout medical school where it never had been before.

PND: What, if anything, was removed from the curriculum?

GM: We didn’t give up much, as there was redundancy, there were gaps, there were things done out of sequence and therefore had to be repeated. When you brought together the parties all who were teaching the same material, it could be done in a much more effective way. We probably gained around 20 to 25 percent of time to add in other things like case developments, panels, site visits to hospices, nursing homes, geriatric centers and managed care centers to see what utilization review takes place.

PND: The government is now paying hospitals to not train residents. How is the problem of physician oversupply factored into your newly designed curriculum?

GM: Well-trained U.S. physicians probably will have no difficulty in securing good residency training programs. Government policy will have the greatest impact on foreign medical student graduates. I see it having much less of an impact on U.S. graduates. American and Canadian programs are probably the strongest, relative to the majority of the world and therefore, when you look at those students that obtain the choice positions in most of the residency training programs, they’re primarily U.S. graduates. I don’t see that changing that dramatically.