Harvard Paves a 'New Pathway'

Generations of doctors have experienced the nightmarish rites of passage through medical school--eight-hour lecture days, and an insurmountable barricade of raw knowledge.

And despite widespread criticism, the conventional system of medical education--in which the first two years stress factual knowledge, while the last two emphasize clinical skill--has gone virtually unchanged for 30 years. Some critics have called it dehumanizing and disjointed, charging that too many physicians turned out through the traditional route have been insufficiently prepared to handle patients in a caring and effective way.

But the Harvard Medical School is out to challenge the critics, and this fall began a pioneering experiment that officials view as a better way to produce better doctors.

Instead of spending hours upon hours in lectures, and waiting two years to start clinical work, this fall 24 first-year students--almost a sixth of the Med School class of 1989--are participating in the school's New Pathway program. It is designed to allow students to start thinking clinically from the start of their studies, and decrease the amount of required memorization.

New Pathway "is aimed at trying to determine what kind of training all physicians should share, no matter what they do," said Professor of Anatomy Dr. M. Judah Folkman, one of the program's teachers.

Although the program is just two months old, plans to broaden it to include a larger proportion of each Med School class--and perhaps one day all medical students at Harvard--are already underway, according to Dr. Daniel C. Tosteson '44, who as dean of the Med School has led efforts to establish the program.

"We've been actively discussing [extending it] in various groups, but we have no set timetable," Tosteson said recently.

Students in the program spend five hours a week in six-person tutorials, each led by a faculty member experienced in the question-answer Socratic method. (For more on the tutorial experience, see accompanying story, Page One.)

They also spend 90 minutes in lab each day, and just six hours weekly in lectures, about one-quarter the typical amount. The lectures are designed to be more conceptual than those taught according to the traditional conception of medical education.

In addition, students spend four hours each week learning clinical skills, and about three hours weekly in "Patient/Doctor," a class which covers many of the interpersonal and moral aspects of medical life.

A Long Haul

The New Pathway was conceived three years ago as a radical new approach to training doctors, a seven-year plan that would have taken students after their sophomore year in college and carried them through one integrated chain encompassing the final two undergraduate years, four years of med school, and the first year of "residency," or hospital training.

But problems in persuading the Med School faculty to accept the full plan, and the realization that it would be difficult to fashion a comprehensive college-med school-hospital program, led organizers to settle for revamping the traditional four years of medical training for no more than 25 students in each class.

After the Med School faculty granted conditional approval to the plan two years ago, a variety of student-faculty committees began refining the curriculum, recruiting faculty, and raising money. Several million dollars and hundreds of agendas later, the first program participants were selected in the spring from among interested students admitted to the regular class.

While Tosteson and others still speak fondly of the grand seven-year proposal, most of their current efforts are aimed at insuring that the fledgling program survives its inaugural year.

And if the early reaction of both students and faculty is any indication, then it may be just a matter of time before the New Pathway becomes the route for all medical students at Harvard.

"The curriculum does seem to be working, and students are learning at a good clip. There's a sense of challenge and creative effort," said Dr. Gordon T. Moore, who chairs the New Pathway curriculum committee and oversees the program's daily operation.

Still, he says, the program has been far from flawless during its first weeks.

"There have been difficulties with faculty and students on how to make tutorials work. It's really hard to find proper materials," Moore said. In addition, he said, "the intensity and number of cases are too much."

"From the point of view of excitement and enthusiasm, it seems to be wonderful," said Professor of Anatomy Dr. Daniel A. Goodenough '66, one of five tutorial leaders.

"But whether this is going to be a substitute for the conventional way of teaching, it's hard to tell," Goodenough said.

Several students interviewed recently offered praise for the program, interspersed with moderate disdain for the traditional route that none of them had experienced but that they seemed glad to have passed up.

Student Mark Silver said the Pathway "is working like a dream." He believes he "definitely gets more out of" the tutorials than he would have from a schedule full of lectures which "go in one ear and out the other."

"It seems to be working very well right now," said student Kenneth D. Mandl. "At first there was a lot of skepticism because we do a lot of clinical work, but now people realize that this is knowledge we're going to be building on."

"In terms of details and facts, we're getting less," said student John K. Parks. Added Silver: "We're not being held responsible for every single detail."

Silver lauded the flexibility of the unconventional program, saying it allowed him to take a course on AIDS and immunology that he could not have taken if he were not a Pathway participant.

Effectiveness

While observers of the New Pathway have applauded Harvard's efforts at reform, some have charged that the program's decreased emphasis on information-gathering will leave students inadequately prepared to tackle the critical end-of-school licensing exams.

Though Tosteson said "they will certainly be ready," not everyone is so sure.

"We don't even know that we're doing things right yet," said Dr. Elio Raviola, one of the tutors. "I have a pretty good feeling, but it's a bit too soon to say anything."

Goodenough said he does not think students will be hurt by their unconventional preparation. He was quick to add, however, that the license exams in question--among them the National Board of Medical Examiners Test--are badly designed, posing "Petty questions, testing how many facts have been crammed" into students heads, instead of conceptual understanding.

Without question, Goodenough said, New Pathway students should be better prepared than others for the clinical exams, which are a battery of tests given in addition to the licensing tests.

Mandl was among the students who said he wasn't concerned about the prospect of being inordinately challenged by the exams.

"The classic curriculum prepares more directly toward the boards, and we're about as far away as you can get from just preparation for the boards. But hopefully, we'll retain more of what we've learned," he said.

Few connected with the New Pathway program are willing to predict that the future will be without problems. In fact, some have already raised concerns that were not anticipated during the program's planning. Among them: the nature of the program has made it tougher for the 24 Pathway students to feel as if they are part of the Class of 1989, which has some 140 additional members.

"We need to make an active effort to integrate socially," said Mandl.

Another problem considered potentially serious is the prospect that the Pathway students will be perceived by others at the school as the faculty's favorites, or otherwise more special than the program's planners had intended.

While most downplayed this, Goodenough termed the possible perception of preferential treatment as "problematical."

But, he said, working through the problems that come up this year may prove critical to the program's overall success, and possible future expansion.

For if Harvard weren't considering making the New Pathway the regular pathway at the Medical School, Goodenough said, "we wouldn't be doing it at all."