The Medical School: An Increase in Clinical Training

If things go his way over the next few years, Dr. Daniel C. Tosteson `44 dean of the Medical School, may radically transform the way medicine is taught at Harvard and elsewhere around the country.

Tosteson believes the nation will ultimately need a more comprehensive approach to medical education, producing physicians trained to use newly developed medical technology. For the interim, however, Tosteson has helped engineer a set of preliminary curriculum changes that will go into effect this fall--changes that this year sparked a small storm of student dissent that only now is beginning to subside.

The revised curriculum will mostly affect future third-year students, who will be required to take more clinical training in place of previously required concentration courses. The school will also add and revise several courses in the first two years, allowing these "pre clinical" years to provide hands on experience for clinical training "clerkships."

Before the Medical faculty approved the changes last January, first and second year students expressed their disapproval of the plan in an informal referendum. They charged that the new curriculum particularly the increased clinical workload would but back on the freedom of choice enjoyed by previous classes. At first faculty members were outwardly sympathetic towards the students, allowing them to air their views at meetings of the student-faculty curriculum committee. Yet the final outcome suggests that the concerns of the first two classes - who will be the only current students affected by the changes had little impact.

The committee "observed the letter, but not the spirit of having students involved," says Bill Betcher, a second-year student who helped conduct the student poll Betcher added that in "providing lip service to the exchange of views," the faculty created an atmosphere of mistrust even around proposals "that actually had some merit."

Most of the controversy surrounds the changes in the number of mandatory clerkships required of third-year students. Under the old curriculum, all students had to take five months of clerkships in surgery and medicine, and could choose from among five other areas to fulfill an added three months of clerkship slots. The new plan increases the number of mandated clerkships from eight to 12, and eliminates any student choice among clerkships.

Faculty members on the curriculum committee called additional mandated clerkships necessary to insure that all students would graduate with exposure to all crucial medical areas. More than 75 percent of students were already opting for such a broad program, so the added requirements are aimed at the minority of students which enrolled in esoteric or other "non-essential" courses, says Dr. Leon Eisenberg. Presley Professor of Psychiatry and one of the faculty chairmen.

"I guess it's a swing, but it's hardly a revolution." Eisenberg says. The stiffened requirements, he adds "puts us in step with 98 percent of the country's medical schools."

Eisenberg says the outgoing Med School curriculum was encacted with its minimal requirements in the late 1960s, when student protest led to efforts "to make the Medical School a little less of a trade school and more of a graduate school."

The school has also eliminated a "concentration" requirement in the fourth year, consisting of an additional four months of clerkships left to the students' choice. Both students and faculty agreed that the requirement had become "dysfunctional," because of logistical problems within some of the topics of concentration. Thus, says Myra B. Ramos, assistant to the dean for academic affairs, the number of total required clerkship months is the same as before, with the major change being that students are now told which 12 clerkships they must take.

Besides the clerkships in medicine and surgery, third-year students must now take one-month terms in neurology, obstetrics and gynccology, pediatrics, psychology, and radiology, and two weeks each in orthopedics, dermatology, opthamology, and ear, nose and throat.

Jane Weeks, another second-year student who helped coordinate the student vote, says that while she believes making the clerkships mandatory is a mistake, the changes "reflected a legitimate concern that there were students graduating from the Medical School who just didn't know certain things."

"The school should have encouraged people to think more about their medical education for themselves," says Peter Slavin, a second-year student. He argues that the school should have effected the changes through its advising system--allowing the variations in clerkship selection "that have to be expected with such a diverse class."

Although he favors "anything that works towards students assuming responsibility for their own education." Tosteson adds that the changes reflect merely a "swing towards a clearer delineation of expectations."

"There was a feeling that exposure to these subjects is so important that it would be better if these were indicated unequivocally as a requirement rather than as a matter of choice," Tosteson says.

As the first step in an overall plan to reevaluate the medical curriculum. Tosteson sees the recently enacted changes as only marginal; he hopes eventually for an experimental project at the Med School that would accept some students after two years of college and expose them to a broad seven-year medical program.

The plan is currently undergoing preliminary discussions, but if it is approved. Tosteson hopes that it will eventually clear the way for a similar overall plan at the Med School. But, he says, sweeping alterations would not be considered for at least several years.