1.01 Plan of Instruction for Cannon, Castle, Holmes, and Peabody Societies (Pathways and New Pathway Programs)

Medical Education

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1.01 Plan of Instruction for Cannon, Castle, Holmes, and Peabody Societies (Pathways and New Pathway Programs)

The curriculum of Harvard Medical School integrates the biological, social, behavioral, and clinical sciences over a four-year period.

Pathways Curriculum (new in AY16)

Beginning in August 2015, Harvard Medical School will launch an innovative new curriculum – Pathways.  This bold revision of the MD curriculum will incorporate pedagogical approaches that foster active learning and critical thinking; earlier clinical experience; and advanced clinical and student-tailored basic/population science experiences that will provide customized pathways for every student.

The core basic/population science knowledge needed to succeed in clinical clerkships will be taught prior to the core clinical year, while the richness of more advanced science that is best suited to students after they have had intensive clinical experience will follow completion of the core clinical clerkships. After the intellectual transformation that occurs during the core clinical year, students will be more receptive to courses in advanced scientific and clinical topics; required and/or selective courses in pathophysiology and pharmacology; selective courses in basic/translational science, social/population science, and medical humanities; individual, faculty-mentored scholarly projects; clinical electives and subinternships; and Steps 1 and 2 of the national boards.

Foundational Pathways

The Pathways curriculum begins with the foundational building blocks to study medicine, including fundamentals of anatomy, histology, biochemistry, and molecular and cellular biology; genetics; immunology; and introductory pharmacologic principles. This introductory period includes two new courses, Foundations and Immunity in Defense and Disease, designed to equip students with the knowledge to navigate the study of organ systems.  These two courses will be followed by a month focused on the fundamental social and population sciences – health care policy, social medicine, clinical epidemiology and population health, and medical ethics and professionalism - to provide a foundation of knowledge on which students will build throughout the four years of medical school. The remainder of the preclerkship curriculum will be organized around organ-system-based modules – Homeostasis I and II and Mind, Brain, Behavior and Development – during which structure and function, and normal and abnormal processes for each organ system will be integrated—anatomy, physiology, pathophysiology, pathology, pharmacology, imaging, and nutrition. In this design, students will learn about two complementary organ systems simultaneously in parallel blocks, which allows students more time to digest each system and difficult concepts; to consolidate learning; and to appreciate the complementarity between systems. From the first week of medical school, beginning with the Introduction to the Profession, students will be engaged in a longitudinal clinical course, The Practice of Medicine, which will be integrated with the basic and social science courses, and during which students will learn the fundamentals of patient-doctor communication, the physical exam, the dynamics of working in clinical teams and systems, and the process of developing a differential diagnosis.

The Pathways curriculum fulfills an aspiration for earlier clinical exposure by moving the Principal Clinical Experience (PCE – core clinical clerkships) into Year II. The new preclerkship clinical skills course, Practice of Medicine, will be integrated with the longitudinal Primary Care Clerkship during the PCE, yielding the potential for two years of continuity in a single ambulatory-medicine practice.

New Pathway Curriculum

During the first two years of the New Pathway curriculum, emphasis is placed on the biological sciences, which are closely correlated with the social and behavioral sciences. As the student progresses, the clinical sciences come to the fore, and the venue of education transfers from the School’s Tosteson Medical Education Center (TMEC) to the multiple hospitals, clinics, and medical care facilities affiliated with the School.

In the first and second years, the curriculum focuses on the Fundamentals of Medicine (FOM), the introductory biological, population, and social sciences and clinical experiences that prepare students for the study of clinical medicine. Laboratories, conferences and lectures complement a problem-based approach that emphasizes self-directed learning in small-group tutorials facilitated by a faculty tutor. The tutorial format allows students to identify their own strengths and weaknesses in various subject areas and to benefit from the talents and perspectives offered by others in the group. Students are expected to analyze problems, locate relevant material in library and computer-based resources, generate hypotheses, and develop lifelong habits of learning and independent study. In addition, students are expected to assume responsibility for their own learning and to contribute to the education of their colleagues. All students are expected to participate actively in the tutorial learning process.

Fundamentals of Medicine

Curricular design at Harvard Medical School emphasizes content integration within and across many of our courses. The first-year curriculum is designed to build from molecules to cells to organisms, beginning with a molecular framework that integrates seamlessly with the transition to anatomy. In the second year, the teaching of pathophysiology is presented in an integrated way that incorporates aspects of pharmacology, pathology, and nutrition associated with individual systems. In addition, a sequence of courses in medical ethics/professionalism, social medicine, clinical epidemiology, scholarship in medicine, and health policy are integrated with the teaching of the basic biological sciences and with introductory clinical exposures.

  • Introduction to the Profession, the first course required for all entering medical and dental students, is designed to provide a broad overview of the profession from a variety of perspectives; to introduce students to problem-based, collaborative learning; and to clarify the goals, expectations and demands placed upon students as they make the transition to physicians-in-training.
  • Biomedical sciences are presented through a sequence of block courses extending through the first year and most of the second year. These courses encompass the following areas: the morphological sciences; the biochemical, pharmacological and physiologic sciences; the developmental and molecular biological sciences; pathological, microbiological and immunological sciences, and the neurosciences.
  • Social and population sciences are learned through a sequence of required first-year courses in social and population-based medicine. This sequence, which addresses important issues confronting physicians in the 21st century, includes Introduction to Social Medicine and Global Health, Clinical Epidemiology and Population Health, Health Care Policy, and Medical Ethics and Professionalism. These courses present students with an introduction to the social factors that influence health and disease both domestically and globally; the principles of clinical epidemiology and biostatistics required for the evidence-based practice of medicine and critical appraisal of medical literature; an overview of health care policy issues and options; and the ethical dimensions of medical decision-making.
  • Pathophysiology is presented throughout most of the second year in Human Systems, a course organized around organ systems. This course is designed to provide close correlation between structural and functional changes in disease and the ways in which these changes become manifest at the clinical level. A focus on the pharmacology, nutrition, and pathology of individual systems is integrated into the study of each organ system and its physical examination.
  • Clinical skills and the patient-doctor relationship are addressed in a three-year sequence. Instruction in history-taking and physical examination is presented in the first and second years. Economic, social, and ethical aspects of patient care in the context of the clinical clerkship experience are examined in the third year.
  • Scholarship in Medicine. Beginning in the Fall of Year I, students receive formal training for the Scholarship in Medicine requirement. An introductory course, Pursuing Inquiry in Medicine, orients students to the range of options and resources available to meet this requirement. Beginning with the Class of 2015 (students who matriculate in August 2011 and later), all students are required to complete a project proposal as part of the introductory course in one of six areas of scholarly inquiry, which may be submitted for funding as a summer project following Year I. Students who matriculate in August 2011 and later are required to complete a scholarly project in one of these five general areas  of inquiry – biologic and translational research; global and community health (including primary care); health care policy and health services; medical humanities; or outcomes research, quality improvement, and clinical epidemiology - prior to graduation.

The Principal Clinical Experience – New Pathway and Pathways

The core clinical curriculum - in the third year for New Pathway students and in the second year for Pathways students  - provides a clinical base for exposure to the broad disciplines of medicine and experiences essential to credentialing as a licensed physician. During this year, students often make decisions about career choice. The Principal Clinical Experience (PCE) is an integrated approach in which the clinical year occurs primarily at a single site (Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Cambridge Health Alliance, or Massachusetts General Hospital; for the Beth Israel Deaconess and Brigham and Women’s Hospital PCEs, Boston Children’s Hospital provides the pediatrics experience). The PCE is a 12-month integrated program of study (running from April of Year II through March of Year III for New Pathway students beginning the PCE in 2016,and from October of Year II through September of Year III for Pathways students, beginning in October 2016) comprised of clerkship rotations lasting 4-12 weeks and supplemented by a longitudinal multidisciplinary curriculum that incorporates mentoring, assessment, and ambulatory care experiences. All students are required to complete the 12-week Medicine and Surgery clerkships, the 6-week Pediatrics and Obstetrics and Gynecology clerkships, and the 4-week Neurology and Psychiatry clerkships during this 12-month period. Because radiology is such an integral part of all clinical clerkships, students will learn radiology/imaging longitudinally during all PCE clerkships. Beginning with the Class of 2015 (students who matriculate in the New Pathway curriculum in August 2011 and later), the 4-week Radiology clerkship may be taken during the PCE or may be postponed until Year IV, allowing students in the New Pathway 1 month during the Year III PCE to work on their scholarly projects or to devote to other academic priorities. Students are also required to complete the longitudinal components of the PCE, which run in tandem with the block clerkships and include the multidisciplinary PCE course; the Primary Care Clerkship, which runs from September to April for New Pathway students; and Patient-Doctor III. Students at Cambridge Health Alliance are enrolled in the Cambridge Integrated Clerkship and follow panels of patients rather than learning clinical subjects in departmental block clerkships.

Advanced Experiences in Clinical Medicine and Basic Science - New Pathway Curriculum

The 12-month period comprising Advanced Experiences begins in April of Year III and ends in April of Year IV. Because the November-December-January period in Year IV is traditionally devoted to residency interviews (students usually are unscheduled for 2 of these months) and completion of Step II CK and CS of the United States Medical Licensing Examinations (USMLE), approximately 11 months remain for student course work. During this period, students must complete a set of academic requirements, as defined below:

  • Required subinternship:  Following the PCE, students are required to complete a Medicine II or Advanced Pediatrics clerkship prior to March of Year IV. This required subinternship must be taken at an HMS site other than the site to which the student was assigned for the Principal Clinical Experience. A second subinternship in a surgically-oriented discipline is highly recommended but not required. Students are advised to complete the subinternship between May and November of HMS IV.
  • Elective experiences include more specialized clerkships (e.g., hematology, emergency care, dermatology); advanced courses in pathophysiology (e.g., oncology or infectious diseases); laboratory and field research. At HMS alone, approximately 200 electives are offered each year. Students also have access to courses offered by other faculties at Harvard University and at Massachusetts Institute of Technology. Courses drawn from any of these faculties or institutions may be chosen to make up the elective program and to fulfill the course distribution described under Graduation Requirements as long as these courses pose no conflict with clinical clerkships in which the student is enrolled. During this year, courses/clerkships may also be taken at other medical schools and medical centers in a chosen specialty, and students may participate in global health electives abroad, scientific research, and other educational experiences. (N.B.: Course credit will be awarded for no more than two similar electives in the same discipline. Eight weeks of clinical electives must be taken at a Harvard Medical School-affiliated clinical institution.)
  • Capstone course:  This course, entitled Into the Wild Blue Yonder – Preparing for Internship, reviews and reinforces the skills necessary to manage common medical problems and procedures; refocuses students on the importance of professionalism and compassion in caring for patients; and helps students transition to the demands of internship/residency training. The course is currently recommended but not required for graduating students. See the HMS Course Catalog (http://www.medcatalog.harvard.edu/) for information about boot camp courses for students who have matched in either a surgical specialty, ob/gyn, or emergency medicine. There is some coordination between specialty boot camps for preparation for residency and the Capstone course.

Years III and IV - Pathways Curriculum

An important feature of the Pathways curriculum is the opportunity for students to customize their route through Years III and IV to prepare optimally for whatever aspect of the profession of medicine has attracted their curiosity and passion. While rigorous demands and high expectations will be set for students in Years III and IV, the expanded time following the PCE allows for considerable flexibility as students pursue advanced integrated science courses, clinical electives, and scholarly research projects, and take advantage of myriad opportunities across Harvard University and around the world.

The Pathways curriculum organization acknowledges that core basic/population science knowledge and skills are needed prior to the clinical year, but that the richness of more advanced science is best suited to students who have already had clinical ward experience. The expectation is that, having lived in a clinical context for a year, students will return to be more engaged in learning advanced basic and population sciences that are now much more relevant and compelling to them.

Requirements in Years III and IV of the Pathways curriculum, beginning in October of Year III, are still being determined but will include, at a minimum, a subinternship in medicine or pediatrics; a minimum number of clinical electives at Harvard-affiliated hospitals; at least four months dedicated to a scholarly project; and a minimum number of advanced integrated science courses. Students will also complete and pass USMLE Step 1 and Step 2 CK and CS as a requirement for graduation following the PCE year of the Pathways curriculum (see Section 1.03).