Medical Education

The curriculum for educating physicians in the United States has evolved through four phases since the first medical school was established in Philadelphia in 1765.

• • Phase I—The apprenticeship era (1765–1871). During this period a student's ability to pay tuition and not his or her academic qualifications was the sole criterion for admission into medical school. The program involved two four-month semesters of classroom attendance, with no patient contact. This critical educational gap was followed by a one- to three-year apprenticeship with a private general practitioner, chosen by each student. Upon completion of this interlude the individual embarked upon a career as a medical practitioner.
• • Phase II—Discipline-centered era (1872–1951). During this lengthy period, which was the traditional curriculum for many decades, the faculty was organized into discipline-specific departments. Both generalists and specialists conducted classroom and clinical instruction. Over time a changed learning environment developed that encouraged students to become independent thinkers, develop medical problem-solving skills, and become active short- and long-term, self-directed learners. Ultimately, a traditional four-year curriculum developed, consisting of two years of basic science and two of clinical training. After the fallout from the Flexner report (see page 4), this arrangement became the standard for all U.S. medical schools.
• • Phase III—Organ system era (1951-present). In this curriculum, the basic and clinical sciences are integrated within an organ-system framework. The appeal of this program, which remains a component of many current curricula, is due to the belief in the independent integration of information during clinical training, and the utilization of learning objectives. It involves program design by curriculum topic, which is a more effective tool than the rigid disciple-based approach.
• • Phase IV—Problem-based era (1968-present). This program seeks to view the patient from the perspective of a whole person rather than as an individual with some organ system dysfunction. This curriculum is structured within the context of clinical problems. Students are exposed to small-group, problem-based learning. Thus, the educational approach involves a student-centered, active setting, minimizing attendance at large group lectures. Discussions of clinical problems serve as vehicles for integrating the basic and clinical sciences into coherent and clinically relevant learning experiences.

The consequences of the curricular changes that have taken place during Phases III and IV are discussed on page 414 under The New Medical School Curricula. As this title implies, curriculum modification and innovation is, as it should be, an ongoing process.

Recent reports suggest that we may soon be entering Phase V, with the development of a Clinical Presentation Curriculum. This approach focuses on the manner of patient presentation, which serves as the context for imparting to students relevant basic and clinical science information.