Chaim Potok said “All beginnings are hard”[1]. This is as true of starting first grade as starting each new year in medical school.Beginning a new educational curriculum has much in common with beginning to see patients. How do we write the doctor’s scripts so that generations will benefit? This interface of new curriculum and clinical experience is central in the education reform initiative at Harvard Medical School, now transitioning the “New Pathway” curriculum, launched in 1985, into a new plan, called “Building Bridges.” The new curricular highway will have four “lanes”: education, research, clinical care, and community service [2]. Central to all is the “Principal Clinical Year” (PCY), traditionally third-year Harvard Medical School students’ transition into seeing patients. The new curriculum hopes to fine-tune the old model for third-year rotations, a series of short experiences (clerkships) in different HMS teaching affiliates, to a more longitudinal approach, where all or a large part of the third year is spent in a single institution.

Before launching the new “Building Bridges” curriculum, however, three pilot programs offer HMS3 students a chance to experience and shape the PCY component. The first pilot, which started in 2004 at Cambridge Hospital, offers all of its eight students an “Integrated Clerkship” that entirely replaces traditional block rotations with a year-long immersion, for each student, in the illnesses, treatments, and lives of some 40 to 50 patients throughout the year, beginning with their initial symptoms [3]. The second pilot, which launched in July 2005 at Brigham and Women’s Hospital, follows 12 from the class of 60 total HMS3 students at BWH in another variant of this longitudinal model. A third pilot is underway with 8 students at the Beth Israel-Deaconess Hospital. The PCY experience at BWH retains the traditional clerkship structure, but all twelve students remain at BWH throughout the year (except for their pediatrics clerkship, which takes place at Children’s Hospital). To this foundation, says Dr. Erik Alexander, the pilot’s Department of Medicine liaison, “we overlay additional activities that promote this continuity of education.” The pilot group, for example, shares core interdepartmental curriculum tutorials, an interdisciplinary faculty mentorship “team,” and gets to contribute to the longitudinal core-faculty assessment of each student. The group is further united by being its own “Patient-Doctor” group, unlike other HMS Patient-Doctor groups, which are made up of students in a random variety of hospital experiences. Every other week the PCY group meets for interdisciplinary tutorials, with at least two clerkship directors at each meeting leading collaborative discussion of two different specialties. Students are also expected to take interdisciplinary initiatives outside of formal tutorials and clerkship sessions. In addition to Dr. Alexander, the faculty mentors for the BWH pilot include Drs. Lisa Breen (Surgery), Adam M. Brenner (Psychiatry), Vincent (“Vinny”) Chiang (Pediatrics, at Children’s Hospital), Susan Farrell (Emergency Medicine), Galen Henderson (Neurology), Kitt Shaffer (Radiology), and Michael Stelluto (Obstetrics and Gynecology).

“We viewed this novel curriculum from three different standpoints,” says Dr. Alexander. “The first was better assessment of the student in a longitudinal fashion. The second was improved mentorship of the student throughout the year. The third was a real attempt to improve interdepartmental teaching across the normal boundaries that usually exist in terms of subject matter, and to begin, for example, to work on many topics that don’t fit into any single discipline, such as genetics and geriatrics, and so forth. We’re trying to objectively collect as much data as is possible, though we’re pleased that initial feedback has been very positive. And we hope to really critically look at what works and what doesn’t work.” The current plan, if all goes well, is that the full HMS3 class could enter the new curriculum by 2008. “It’s best called a principal clinical experience,” Dr. Alexander adds, since the precise time frame for longitudinal continuity is one of the factors open to change.

“We hope that by having students in one place,” Dr. Alexander continues, “one of the tangible benefits will be in opportunities to cross specialty boundaries when time is available. Beyond that, an important key is that different physicians view medicine differently. A surgeon looks at fluid replacement differently than a Medicine doctor. The student benefits by beginning to see the different perspectives in one teaching modality. They begin to see a very broad-based approach to medicine. And although we view integration as a very important piece of medical student education, we also recognize the very different types of patient care that each department provides. We want to continue to allow each department to model their type of medicine as they think best. What we bring together are many themes better taught in an integrated fashion.”

The present clerkship model, Dr. Alexander continues, “is itself a very effective and successful educational modality. We are out to try and simply improve on what we already think is good. We do not view the clerkship as something in need of revolution. But we do see the benefits to the students—and to the educators—to begin working in much more of a hospital environment as opposed to just a departmental environment.” Within that hospital environment, the new model will, it is hoped, “provide the student again with a more practical education for the challenges that lie ahead in the 21st century of medicine. It also allows for a real scholarly activity towards the end of their third and then into their fourth year. Also, we are very interested in making this a curriculum flexible enough to adapt to our MD/PhD students, or to students who take time away for other educational purposes, such as separate degrees at Harvard School of Public Health, Harvard Business School, or for a year abroad to study international health or policy.”

How do participating HMS students feel about the experience? “The PCY program is enhancing what is already great about a fantastic program,” says Josh Nassiri, who came to Harvard Medical School from the Naval Academy, after a year at Oxford as a Rhodes Scholar studying the history of modern military medicine. “Because it was a pilot program I knew, going in, that we would have motivated teachers, motivated students.” “The program was completely compelling to me,” says Christine Pace, who came to HMS following a predoctoral fellowship in clinical bioethics at the NIH and who is a founding member of the nonprofit organization, Students for Environmental Awareness in Medicine (SEAM). “I was excited by the idea of moving through my third year with a community of students and faculty whom I could get to know. I loved the idea of being able to reconnect with faculty and residents I'd met in prior rotations. I had heard wonderful things about the BWH clerkships and knew that I would only gain in terms of my learning by doing all my core rotations here. Also, I have an abysmal sense of direction. Since I still can't find my way to the Linens department without getting lost, I think it's particularly wise that I'm not changing hospitals too much this year.”

Extra quality time to focus on clinical care is another advantage of being in one place all year, says Josh. Students can plunge right into seeing patients on the first day of each rotation, since they already have a BWH ID and Partners email, and know how to use the computer, write orders, access pharmacy, radiology and call rooms, and they know where the bathrooms are. Both Josh and Christine praised the pilot program for its team-building. “In our PCY group I am more likely to talk about particular frustrations with rotations, since I know others in the group can say ‘This is something you need to know because if you haven’t gone through it, you will.’ And offer solutions,” says Josh. The teamwork both helps to improve clinical education and encourages negotiated interactions in addressing potential interdisciplinary barriers with and among faculty. The interdisciplinary focus also encouraged Josh to give a presentation recently on his area of interest, system versus medical error, and what the medical establishments can learn from other industries, like aviation and nuclear power.

Is time a problem, adding these pedagogic layers to an already-busy third year? “I think it’s a mistake to think third year is so busy we can’t add anything,” says Josh, who is currently in his psychiatry rotation. “I don’t think that students get frustrated by demands on their time, but by needless demands on their time. It was established from the very beginning that the extra components are there for a reason. There was a sense that as long as this is productive, students will find time. The feedback on our Patient-Doctor group, for example, has been uniformly positive, and for the last two years it was rated the lowest class at HMS. I think it’s great to be able to turn that around – and to know too that if something isn’t working, we can say, ‘this isn’t working. This needs to change.’ And that has happened.” Christine, who is currently in a very demanding Ob/Gyn rotation, says, “it will be a challenge to make time to take full advantage of what we could gain by this program, in terms of meeting with those we worked with on previous rotations.” Even so, she is delighted at the opportunity for the chance at patient continuity. “Because I did all my Medicine ambulatory weeks at BWH, for example, I was able to see two of the patients I met during my inpatient months at outpatient specialty clinics. I loved being able to reconnect with those patients in a new setting, hear how they were doing, and to learn more about their conditions from a specialist.”

Like any new curriculum, the PCY model presents certain challenges. “It will take time to accurately assess and to build the bonds to make this a lasting educational process,” says Dr. Alexander. And what works with a pilot group of eight or twelve students may require further changes in order to work well with sixty. “We are going to be very diligent in promoting only what truly makes this a better experience,” says Dr. Alexander. From a student’s perspective, learning from just one hospital may have its limits, too. Different hospitals, for example, may or may not offer clerkship experiences such as Emergency Medicine. But there is always fourth year. “I just decided that I would make a special effort to get to know other sites by doing fourth year electives elsewhere,” says Christine. Josh also considers fourth year a better time for moving from place to place. “In fourth year you’ve already got your clinical experience and you’re ready to learn how things are done differently. Right now we have mentors in every specialty. So if I am following a patient in psychiatry and the patient goes to surgery, I know whom to call to ask if I’d be able to track the patient. And that mentor knows me. Can that be maintained with 60 students? I don’t know. I like to think that it could be. But for now, there’s no down-side, no risk.”

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