Harvard Medical School

Medical Education Program Highlight Harvard Medical School (HMS) offers its students a unique educational environment that includes 15 outstanding affiliated hospitals and the largest medical school biomedical research enterprise in the United States. Harvard enrolls 165 medical students annually who have the opportunity to learn medicine from over 11,000 faculty. A robust advising system helps students connect with mentors as each student’s interests develop. A 3-phase curriculum offers flexibility in the final phase for all students to choose from hundreds of electives and pursue a scholarly project in areas including basic/clinical research, global health, public policy, or medical humanities. HMS students also have access to degree programs at the other professional schools across Harvard University and at the Massachusetts Institute of Technology (MIT). The Pathways curriculum enrolls 135 MD students annually and is highly integrated, weaving basic/social science and clinical experiences weekly and across curricular phases with an innovative form of pedagogy, case-based collaborative learning (CBCL), designed to develop critical thinking and collaboration skills for lifelong learning and high levels of student engagement. In collaboration with MIT, the Health Sciences and Technology (HST) program is a unique curriculum track for 30 students admitted annually who are committed to careers as physician–scientists. Curriculum Curriculum description The Pathways curriculum is highly integrated across 3 phases: The preclerkship phase (14 months) features integrated basic and social science blocks and a weekly longitudinal Practice of Medicine course, introducing students to fundamentals of the physical exam, communication skills, and interprofessional collaboration. Harvard dental students join Pathways students in the phase, and all students begin regular meetings with faculty advisors through the Academic Societies. Pathways students are assigned to 1 of 4 Harvard teaching hospitals for their Practice of Medicine course and remain at that site for the next phase of the curriculum. The principal clinical experience (PCE) phase (12 months) begins in the fall of year 2 and includes immersive clerkships in core clinical fields, a longitudinal primary care clerkship, and longitudinal case conferences and advising at each PCE site. The post-PCE phase (19 months) provides flexibility for students to pursue an individualized curriculum, including: A required subinternship in medicine. A minimum of 3 advanced clinical clerkships at HMS-affiliated hospitals, selected from over 250 offerings. A clinical capstone month during the final semester of medical school to prepare students for internship; this features subintern-level clinical responsibilities and special sessions designed to help students identify areas of focus as they start internships. Two Advanced Integrated Science Courses (AISCs): innovative courses cotaught by basic and clinical scientists to allow students to explore the boundaries between the known and unknown after completing PCE clerkships. A month of advanced topics in social/population sciences and health systems-/value-based care, building on students’ clinical experiences during the PCE and advanced clinical experiences; this course is an advanced rejoinder to the first-year course, Essentials of the Profession, which introduces Pathways and HST students to topics in social medicine, medical ethics and professionalism, health policy, and clinical epidemiology and population health. A scholarly project, through which each student is challenged to delve deeply in an area of interest in basic or clinical research, global health, medical humanities, social justice, or another area of interest. Opportunities during the post-PCE phase for a majority of Pathways and HST students to extend their medical education by an additional year of enrollment; about half of these complete a project focused on research, international health, advocacy, or entrepreneurship, and another half pursue a PhD or master’s degree. See Supplemental Digital Appendix 1—Pathways Curriculum Map—at https://links.lww.com/ACADMED/A865. Curriculum changes since 2010 The innovative Pathways curriculum was launched in 2015 after an intensive 3-year planning process involving large numbers of faculty, students, and staff who engaged in a bottom-up curriculum and pedagogical reform initiative. A survey of research on learning theory and educational outcome studies led to a focus on interleaving key content using a flipped classroom model. Implementation required a multiyear effort to create concept videos and other preparatory materials customized for Pathways learners. Pilots were conducted with different forms of pedagogy, resulting in the novel CBCL model. Education spaces in the medical education center were renovated to optimize educational form–function correspondence. The new pedagogy also required extensive faculty development and an entirely new assessment system. In addition to a complete overhaul of the content, structure, and pedagogy of the preclerkship curriculum, the Pathways reform frameshifted the PCE from year 3 to year 2, requiring a one-time overlap of 2 classes during academic year 2016–2017. This shift required extensive planning; financial resources; and hospital, faculty, staff, and student support. The frameshift of the PCE year allowed creation of the new AISCs that are now a highlight of the post-PCE phase. These courses range in subject area from cancer biology, immunology, genetics, pharmacology, and neurobiology to computationally enabled medicine, translational bioengineering, metabolism/nutrition, global health, and health systems science. The new clinical capstone course, required for both Pathways and HST students, was designed as a 1-month intensive subinternship with a focus on complex communication skills needed for internship and opportunities for each student to assess their own areas of continued development as they approach residency. The HST program introduced 2 new courses for first-year students: Matlab for Medicine, a hands-on introduction to quantitative methods in medicine and health research; and Growth of the Physician Scientist, an integrated, yearlong experience designed to support the personal and professional transformation from student to physician–scientist, building on the themes of patient care, community, mentorship and role modeling, and reflective practice. Assessment In 2017, the Program in Medical Education (PME) established the new Office of Educational Quality Improvement (OEQI) to manage new student assessment and curriculum evaluation systems. The OEQI tracks curricular and student outcomes through an education data warehouse, which draws data from students’ academic records, course exams, and objective structured clinical examinations (OSCEs), and students’ evaluations of teachers, courses, and clerkships. The OEQI staff generate reports on student progress that correlate student performance with other key metrics, demonstrate comparability of learning outcomes across clinical sites, and perform many other important assessment and evaluation functions. With the launch of Pathways, HMS also implemented the AAMC’s Entrustable Professional Activities (EPAs) framework as the basis for all clinical evaluations. Relevant EPAs were mapped to courses and clerkships in each of the 3 curricular phases, and rubrics were created to provide developmentally appropriate feedback to students on all EPAs. Students have been graded satisfactory–unsatisfactory (S–U) in the first 2 years of the HMS curriculum for many decades, and this continues. To maintain S–U grading in the first half of the MD program, grading in the core clerkships (now in year 2) was converted to S–U in 2016, when the first class of Pathways students entered the PCE. Students continue to receive quantitative and qualitative feedback in their core courses and clerkships. The required subinternship in medicine and all elective advanced clerkships/subinternships continue to be graded using the honors-with-distinction, honors, pass, unsatisfactory scale, which is also used for departmental summative assessments that grade students by clinical discipline based on their 4-year clinical performance. Formative and summative narratives of student performance are provided in required and elective courses. USMLE Steps 1, 2 CK, and 2 CS examinations are taken after the PCE phase; students must pass all 3 and a multistation OSCE administered at the end of year 3 as requirements for graduation. In parallel with the above, a broad-based process involving focus groups, benchmarking from other schools and the ACGME, and attention to HMS’s mission led to a revision of the MD program objectives. See Supplemental Digital Appendix 2—Program Objectives and Assessment Methods—at https://links.lww.com/ACADMED/A865. Parallel track The Harvard–MIT HST program is a unique partnership between HMS and MIT, annually admitting 30 students committed to becoming physician–scientists to a parallel, 18-month preclerkship curriculum. HST students begin the PCE phase in the spring of year 2. HST preclerkship courses include MIT graduate students pursuing a PhD in medical engineering/medical physics and are taught by faculty from both HMS and MIT. Students are given time to do research for a required thesis during this phase. See Supplemental Digital Appendix 3—HST Curriculum Map—at https://links.lww.com/ACADMED/A865. Pedagogy HMS’s guiding educational philosophy is a belief that meaningful relationships between students and faculty are the most important ingredient in students’ personal and professional development. High levels of support and challenge—balanced through the Society Advisor structure in which each student is known well by a supportive, nonevaluative advisor—enable all students to achieve their fullest potential. HMS’s CBCL pedagogy, developed and tested during the creation of the Pathways curriculum, included a randomized trial with positive outcomes demonstrating a high degree of student engagement and complementarity with other forms of pedagogy employed throughout the curriculum. Students are expected to prepare for each session and work collaboratively in learning studios designed specifically for CBCL. The curriculum also includes some large-group, mostly interactive sessions; laboratories; gross dissections; simulations (including interprofessional); standardized patient encounters; and mentored clinical and research experiences. Clinical experiences One of HMS’s greatest assets is the wealth of clinical experiences available to medical students. Students spend the PCE phase at one of the HMS-affiliated hospitals: Beth Israel Deaconess Medical Center (BIDMC), Brigham and Women’s Hospital (BWH), Cambridge Health Alliance, or Massachusetts General Hospital; students at BIDMC and BWH do pediatrics at Boston Children’s Hospital. Students also have numerous opportunities for clinical experiences at other HMS-affiliated hospitals during the post-PCE phase. All students have a combination of block and longitudinal experiences. Longitudinal experiences include primary care preceptorships in both the Practice of Medicine course and the PCE, along with longitudinal advising and interdisciplinary conferences. The PCE at Cambridge Health Alliance is a longitudinal integrated clerkship. Curriculum Governance The MD program is governed by the Educational Policy and Curriculum Committee (EPCC), a Standing Committee of HMS, created and charged by the Faculty Council, the elected faculty governing body. The EPCC and its 5 subcommittees (Pathways Preclerkship, HST MD Curriculum, PCE, Post-PCE, and Assessment) include faculty and medical students as voting members, as well as ex officio faculty and staff leaders. Other important MD program committees include the Admissions, Financial Aid, and Learning Environment Committees, the Promotion and Review Board, and the Council of Academic Societies, which oversees student advising. See Figure 1—Curriculum governance.Figure 1: Curriculum governance.Education Staff The PME is the organizational structure for the education program that leads to the MD degree. Led by the dean for medical education, with administrative support from the associate dean for medical education planning and administration, the PME includes the Offices of Admissions, Financial Aid, Registrar, Educational Quality Improvement, Curriculum Services, Student Affairs, and Recruitment and Multicultural Affairs; the Academic Societies; and other related functions, including finance, the Scholarship in Medicine Program, disability services, and the Anatomical Gift Program. The advising/mentoring function is supported through the Office of Student Affairs, the Academic Societies, and the Office of Recruitment and Multicultural Affairs. Curriculum and assessment functions are primarily shared by 2 offices: the Office of Curriculum Services, which supports required courses and clerkships with professional staff, and the OEQI (described above), which supports student assessment as well as course and program evaluation. See Figure 2—Education administration.Figure 2: Education administration.Faculty Development and Support in Education The OEQI also provides faculty development for faculty teachers, mentors, and advisors in the MD program. A faculty director of faculty development devises general and tailored programs for faculty across the MD curriculum, as well as resident-as-teacher initiatives. The Academy supports monthly medical education grand rounds; Academy Fellowships in medical education and educational research; annual events such as the Symposium on the Science of Learning and Medical Education Day; and a wide variety of faculty innovation groups in areas ranging from simulation to the hidden curriculum. Initiatives in Progress The structure of the PCE year is currently under review for innovative new models combining the best of block and longitudinal integrated clerkships. In connection with its 50th anniversary, the HST program has launched a major programmatic review, reimagining the best curriculum to prepare physician–scientists for the future

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