Hazards of Change
Rolling out a new curriculum could cause some uncomfortable moments.
I’ve been mulling over a crucial question: What
should a 21st-century medical school education look
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
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