A few years ago, Brian Kobilka, MD, and several of his colleagues noticed something had changed about Stanford’s medical students.
After the medical school’s curriculum was modified to be more clinically oriented in 2003, the number of students who stopped by their offices to ask about conducting basic science research projects had gradually declined.
Kobilka, professor of molecular and cellular physiology and co-recipient of the 2012 Nobel Prize in chemistry, also noticed that Stanford Medicine’s basic scientists had become less involved in teaching since the curriculum change. And those observations troubled him.
“Stanford is a special place,” Kobilka said. “It’s a place where students can learn from and even participate in cutting-edge research when they’re in medical school, partly because it’s a great university, and because the basic science departments in the medical school and undergraduate campus are all contained in a very small geographic footprint. The inflexible curriculum made it difficult for students to take advantage of all that Stanford had to offer.”
Kobilka, the Hélène Irwin Fagan Chair in Cardiology, spoke with a few colleagues. about his concerns and found he was not alone. Among them was Paul Berg, PhD, professor emeritus of biochemistry and a co-recipient of the 1980 Nobel Prize in chemistry. Although Kobilka, Berg and their colleagues could have rested on their own accomplishments in science and education, it was important to them that others follow in their footsteps — or even leapfrog past them — to take up the mantle of discovery at Stanford.
During the next few years, and with support from Lloyd Minor, MD, dean of the School of Medicine, the group grew to include more than 100 faculty, staff and students who spent three years reviewing the program.
Their goal was twofold: first, create opportunities and flexibility for students’ long-term research, personal growth, exploration and discovery; and second, improve the quality of coursework and teaching by adding to the curriculum. The result was a new course of study, called the Discovery Curriculum, that supports both scientific discovery and self-discovery by offering innovative paths for learning and for scholarship.
This curriculum change provides the added benefit of helping to solve another problem confronting medicine: the rapidly decreasing number of physician-scientists in the U.S. workforce. By encouraging and accelerating the education of physician-scientists, the new curriculum may bolster, even in a small way, their dwindling numbers.
“The students, faculty and Nobel laureates who developed our Discovery Curriculum are true innovators in medical education,” said Minor. “Their efforts will facilitate pursuits of fundamental discovery that further our precision health vision, provide our students with a more flexible and distinctive learning experience, and expedite the preparation of physician-scientists to become leaders in biomedical investigation.”
Physician-scientists generally balance their time between research and clinical care. They usually work at academic medical centers, in settings where their clinical practice can inform their research and vice versa. They constitute a shrinking segment of the workforce.
“Over the past 15 years, the number of physician-scientists in their 40s went down from about 7,000 to about 4,000,” said PJ Utz, MD, professor of immunology and rheumatology and associate dean for medical student research. “And the numbers of those in their 60s, 70s and 80s increased. By our analysis, to maintain the numbers that currently make up the U.S. physician-scientist workforce, close to 200 additional physician-scientists need to be trained every year than we are currently graduating across the nation.”
A 2014 report from the National Institutes of Health detailed the challenges for physician-scientists — including longer training times and increasing educational debt — and noted that “the largest group of NIH-funded U.S. physician-scientists continues to be those who hold an MD as their only professional degree.” In other words, while the MD-PhD pathway is commonly regarded as the primary route to becoming a physician-scientist, it does not produce the largest number of physician-scientists.
The report highlighted the value of physician-scientists, noting that those who see patients and perform research can “help identify the mechanisms of disease, as well as apply the findings of basic science to patient care.”
Neil Gesundheit, MD, professor of endocrinology and senior associate dean for medical education, sees this work of basic and translational research as essential to the progress of medicine. “What we want our students to do is not to emulate us, but to eclipse us,” he said. “We want them to gain skills and leadership, knowledge — whatever they need — to become the academicians and the thought leaders, the change agents for the future.”
Second-year medical student William Shi said, “Stanford’s research excellence was a huge reason why I chose to come here. Very few medical schools in the country actively encourage their students to dedicate time for translational and clinical discovery, and even fewer provide the resources that Stanford can.”
The new curriculum is designed to introduce research to medical students earlier in their training to inspire and support their goals for investigation without requiring them to spend seven to eight years to complete an MD-PhD program — the program that combines a clinical education with the establishment of a scientific research specialty. The redesign committees also sought to re-engage basic scientists in teaching, and continually improve the quality of teaching across the board.
“Students come to Stanford knowing about its prestige in investigation and discovery,” said Berg, who played a major role in advocating for and shaping the new curriculum. “We want to instill that same culture into the medical students. And my own experience is: Any success early hooks you. You get somebody who makes an interesting discovery, writes an interesting paper and gets it published — that sticks.”
Quality research takes time
Stanford has long required medical students to carry out scientific research during at least one academic quarter, but the post-2003 curriculum did not allow for longer research projects that span over months or even years. Students who engaged in long-term projects typically took a year off, disengaging from coursework and their classmates. Daniel Bernstein, MD, professor of pediatric cardiology and associate dean for curriculum and scholarship, noted that quality scholarship “often depends on an experience that’s longitudinal.”
Typically between 60% and 85% of medical students at Stanford have opted for at least one extra year of medical school to incorporate other scholarly pursuits, Bernstein said. “When I arrived at Stanford over 30 years ago, this approach was unique among medical schools,” he said, noting that it is still uncommon today.
A small percentage of students opt for the longer road to becoming a physician-scientist, adding three to five years to their MD program to earn a PhD in the biosciences, data sciences, engineering or a subset of social science disciplines. Approximately 10 students each year begin the MD-PhD program at Stanford, also known as the Medical Scientist Training Program, and spend their first two years in medical education before starting full-time laboratory research. After three to five years of research, they complete and defend their PhD thesis before finishing their last two years of medical training, which are dedicated to clinical rotations. Stanford MD-PhD students traditionally are supported through the entire program by a combination of funding from an NIH training grant, individual graduate programs and School of Medicine funds.
Envisioned by Nobel laureates
The Discovery Curriculum began as the vision of a small team of revered faculty that included Kobilka, Berg and Utz. Participating in the early stages of the curriculum’s development were Russ Altman, MD, PhD, the Kenneth Fong Professor and professor of bioengineering, of genetics, of medicine and of biomedical data science; Andrew Fire, PhD, the George D. Smith Professor in Molecular and Genetic Medicine, professor of pathology and of genetics and co-recipient of the 2006 Nobel Prize in physiology or medicine; and Donald Regula, MD, professor of pathology.
In addition to the primary concerns they shared with Kobilka about basic science research and teaching, the group noted that an increasing number of medical schools were reducing the time required to complete their medical degree programs from four years to three in response to a growing shortage of clinicians — a shortfall projected by the Association of American Medical Colleges to reach 100,000 by 2030.
But the Stanford group believed that, for a research-intensive medical school like Stanford, it was urgent to do the opposite: reaffirm Stanford’s commitment to scholarship and discovery and create a pathway for physician-scientists as an alternate to the MD-PhD, which takes longer, costs universities more and often draws graduates away from clinical work entirely into laboratory research.
“At Stanford, we pride ourselves on being the most research-intensive medical school in the world,” said Utz, who graduated from the School of Medicine in 1991. “To advance medicine, scholarship is essential. And not just in laboratory-based research areas, but in other areas such as biomedical informatics, epidemiology, policy and economics, to name a few.”
New curriculum takes shape
Minor took the group’s concerns seriously and, in cooperation with Gesundheit, put the wheels in motion to develop a new curriculum. They started by appointing two administrative committees to undertake the first major curriculum overhaul in 15 years.
“From our earliest conversations, Dean Minor was focused on the future possibilities of a new curriculum,” Utz said. “He could see the need for a uniquely Stanford balance between scientific investigation and superlative clinical training, and helped to ensure it became a reality.”
Preetha Basaviah, MD, clinical professor of medicine and assistant dean for pre-clerkship education, and Bernstein co-chair the committee charged with implementing the Discovery Curriculum. Basaviah spent a decade as one of the directors of the Practice of Medicine course, which began in 2003 and now makes up about 40% of the medical student curriculum.
“Preparing students for clinical care is a top priority of the School of Medicine,” Basaviah said. “We’ve kept a continued focus on clinical excellence with longitudinal mentorship that includes advancing communication and clinical skills as well as professionalism.”
Fully implemented as of this academic year, the Discovery Curriculum includes several restructured courses and some entirely new ones, along with an option to split the second year of medical school into two years to give students large blocks of time for extended research or other pursuits during the second and third years of school.
Among the new courses already underway is led by Kobilka. His participation, as a designer of the curriculum and one of its teachers, is notable. “Usually Nobel Prize winners are off doing other things and not teaching in medical schools,” Utz said. “But ours are here on campus. They’re vocal. They’re in front of the students and deeply involved.”
Time and funding for discovery
Not all students will choose to split their second-year coursework over two years. But those who do will have options for using the unscheduled time; they will also pay the same tuition — and receive the same stipend and housing support — for five years that they would have for four.
Berg said that although some will choose to do research, many of the MD students he interviewed during the redesign efforts expressed a wish to take classes on the university’s main campus and to earn a master’s degree. Students can earn master’s degrees in over a dozen disciplines, including public health, bioinformatics, epidemiology, bioengineering, business and medical education. Students can opt to split the curriculum for other purposes as well — for instance, parenting a new baby, writing a novel or pursuing any other interest or dream, either academic or personal.
The advantage of the split curriculum is that students can start a research project during the spring or summer quarter of their first year and have sufficient time to continue it for the next two years. This type of extended scholarly experience was not possible in the previous curriculum.
“We are, luckily, a medical school in the middle of a major university campus,” Gesundheit said. “The opportunities for dual training for interdisciplinary work are enormous.”
Financial support is also available to students who add a sixth year to earn a newly offered master’s degree in biomedical investigation. A new $2.5 million grant from the Burroughs Wellcome Fund and other funding sources will pay for that additional full year of research, as well as the two years of clinical rotations, for up to five students each year.
‘Feasible and worthwhile’
Students who began medical school in the fall quarter of 2017 and who are now finishing their second year were the first to have the option to split their second-year coursework. Of that group, 11 students — about 10% of the total — elected to do so.
“I jumped at this opportunity,” said Joshua Guild, a second-year student who is researching how alveoli — the tiny air sacs that serve as the site of gas exchange in the lungs — are repaired by stem cells after injury. “The faculty here have done an amazing job of introducing additional flexibility in the curriculum to make an opportunity such as this both feasible and worthwhile.”
Guild’s classmate Shi saw the chance to split his second year as a “sneak preview” into his future career as a physician-scientist. He’s been conducting research into improving diagnostic and monitoring tests for advanced prostate cancer patients, taking part in patient care by volunteering at Stanford’s Cardinal Free Clinics, and taking care of his personal wellness. He’s also advocating for his classmates, in part by leading the medical student mentorship program, which pairs incoming first-year medical students with older students.
Students pioneering in the split curriculum know that their feedback helps refine and perfect the new program. “I’m apprehensive about being the first cohort to split the curriculum,” said second-year student Areli Valencia, who is using the extra time to work toward a master’s in bioinformatics and continue his research. “But I’m also excited because I’m able to design my own path.”
Embarking on such a novel curriculum may feel like a big change for students, but innovation is the point. “We’re persuading students to do the unusual, to be the pioneers,” Berg said. “We built it. Now we want people to come and be a part of it.”
Many students still opt for the traditional four-year clinical medical degree at Stanford, said Bernstein, including many who already have an advanced degree. But for those looking to change the face of medicine, from discovering new treatments to designing better health care systems, the Discovery Curriculum provides a pathway.