Article
The Harvard Medical School Pathways Curriculum:
Reimagining Developmentally Appropriate Medical
Education for Contemporary Learners
Richard M. Schwartzstein, MD, Jules L. Dienstag, MD, Randall W. King, MD, PhD, Bernard S. Chang, MD, John G. Flanagan, PhD,
Henrike C. Besche, PhD, Melanie P. Hoenig, MD, Eli M. Miloslavsky, MD, K. Meredith Atkins, MD, Alberto Puig, MD, PhD,
Barbara A. Cockrill, MD, Kathleen A. Wittels, MD, John L. Dalrymple, MD, Holly Gooding, MD, David A. Hirsh, MD,
Erik K. Alexander, MD, Sara B. Fazio, MD, and Edward M. Hundert, MD, for the Pathways Writing Group
Abstract
Downloaded from http://journals.lww.com/academicmedicine by BhDMf5ePHKbH4TTImqenVA+lpWIIBvonhQl60Etgtdnn9T1vLQWJq3kbRMjK/ocE on 11/02/2020
As the U.S. health care system changes
and technology alters how doctors
work and learn, medical schools and
their faculty are compelled to modify
their curricula and teaching methods.
In this article, educational leaders and
key faculty describe how the Pathways
curriculum was conceived, designed, and
implemented at Harvard Medical School.
Faculty were committed to the principle
that educators should focus on how
students learn and their ability to apply
what they learn in the evaluation and
care of patients. Using the best evidence
from the cognitive sciences about adult
S
ince the Flexner Report established
medical education on a solid foundation
of basic and clinical sciences,1 calls
for medical school reform have been
frequent2 and have accelerated following
the 2010 Carnegie Report.3,4 Common
themes have included more faithful
alignment of medical education with
societal needs and public health,
adjustment to the rapid growth in
biomedical knowledge and contemporary
understanding of cognitive science, and
adaptation to the changing organization
of the health care delivery system.3–9
While advocates for various themes in
health care tend to favor new content
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Richard M.
Schwartzstein, Division of Pulmonary, Critical Care
and Sleep Medicine, Beth Israel Deaconess Medical
Center, 330 Brookline Ave., Boston, MA 02215;
telephone: (617) 667-5494; email: rschwart@bidmc.
harvard.edu.
Acad Med. 2020;95:1687–1695.
First published online March 3, 2020
doi: 10.1097/ACM.0000000000003270
Copyright © 2020 by the Association of American
Medical Colleges
Supplemental digital content for this article is
available at http://links.lww.com/ACADMED/A820.
learning, they made major changes in
the pedagogical approach employed in
the classroom and clinic. The curriculum
was built upon 4 foundational principles:
to enhance critical thinking and provide
developmentally appropriate content;
to ensure both horizontal integration
between courses and vertical integration
between phases of the curriculum; to
engage learners, foster curiosity, and
reinforce the importance of student
ownership and responsibility for their
learning; and to support students’
transformation to a professional
dedicated to the care of their patients
and to their obligations for lifelong, selfdirected learning.
over redesigned pedagogy,9 pedagogical
innovation may have a larger impact on
what and how well students learn; too
often we confuse what we teach with
what students actually learn.
of scholarship in students’ evolution
as developing physicians. As the first
Pathways class matriculated in 2015,
we embarked on a novel approach to
program evaluation, which we plan to
describe in a subsequent publication.
In 2011, with these considerations in
mind, through a faculty-driven initiative,
Harvard Medical School (HMS) began
planning curricular change, based on
the best evidence from the cognitive
sciences (Table 1), culminating in the
2015 launch of the Pathways curriculum.
Our objective was culture change—
from predominantly passive transfer
of information to innovative, highly
interactive, evidence-based classroom
experiences that focus on problem
solving to reinforce concepts and set
high expectations and accountability
for personal and team learning, and
from fragmented, discipline-centered
instruction to highly integrated,
coordinated, collaborative teaching that is
developmentally appropriate for learners.
In this article, we describe the educational
principles and philosophy underlying
Pathways, the resulting approaches to
teaching science and clinical skills, the
assessment of learners, and the role
Academic Medicine, Vol. 95, No. 11 / November 2020
The practice of medicine is rapidly evolving
and will undoubtedly change in multiple
ways over the career of a physician. By
emphasizing personal responsibility,
professionalism, and thinking skills over
content transfer, the authors believe this
curriculum will prepare students not only
for the first day of practice but also for an
uncertain future in the biological sciences,
health and disease, and the nation’s health
care system, which they will encounter in
the decades to come.
Educational Principles and
Philosophy
HMS’s New Pathway, a curriculum
introduced in 1985, had shifted the
balance from large lectures to smallgroup, problem-based learning (PBL)
tutorials.10–13 Over time, however,
we noted that student preparation
was waning, group discussions often
wandered inefficiently down blind alleys,
and experiences varied widely across
different tutorial groups. Between gradual
degradation of student engagement
in tutorials and the changing needs
of millennial learners,14,15 the faculty
recognized the imperative to explore new
teaching approaches that could meet
contemporary learners’ needs.
Armed with the growing science
behind learning techniques that
support enduring learning,16–21 the
faculty–student Task Force on Classroom
1687
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Table 1
Principles of Cognitive Science Embedded in the Harvard Medical School Pathways Curriculum
Principle from the
learning sciences
Definition/explanation
Example
The act of recalling information from memory leads to more
durable long-term recall (also called test-enhanced learning)
Revisiting material learned over time allows for some
forgetting and subsequent effortful recall (see “Retrieval
practice” above)
Students take brief readiness assessments after completing
preparatory study for the next days’ session
Preparatory material presented earlier in the curriculum (i.e.,
in an earlier preclerkship course or in an earlier phase) is
presented again in later courses
Interleaving
Interspersing different materials naturally creates spaced
practice and has the added benefit of facilitating comparison/
contrasting of concepts, pushing students to go beyond
surface features to deeper learning structures
Courses interleave topics from cardiology, pulmonology, and
hematology with dedicated integration days where students
connect the deeper learning within these subjects (e.g., flow
through tubes in homeostasis)
Growth/fixed mindset
Students with a growth mindset are more likely to seek out
new learning opportunities and to be resilient in the face of
negative feedback; students with a fixed mindset are fearful
of challenge, afraid that their inherent capabilities will prove
inadequate
Establishment of relationships with core faculty creates safe
learning environments and frequent encouragement to push
beyond one’s present level of competence; frequent low
stakes assessment, pass/fail grading, robust advising system to
encourage students to choose elective in area of growth
Transfer
Applying information learned in one setting (i.e., the
classroom) to another (i.e., the clinic) is very difficult but
enhanced when students see multiple varied examples and
focus on deep vs surface learning
Emphasis on inductive reasoning from core principles that
can be applied to a wide range of problems; recurring
examples in courses presented in varying ways; weekly push
to practice transfer by embedding clinical day midweek
during the Practice of Medicine course
Mastery learning
Expertise or mastery is cultivated by setting aspirational
learning goals and working with a coach/tutor to get
frequent feedback on progress toward those goals
Scholarly project: chance to work with an expert faculty
member to master a new area; new advising structure
Retrieval practice
Spaced practice
Learning encouraged the adoption of
more effective teaching approaches that
had been shown to foster active learning
and critical thinking, including reserving
classroom time for interactive reasoning
(“flipping” the classroom).22–26 Emphasis
shifted from surface learning to deep
learning—integrated, coherent, linked to
previous knowledge, clinically relevant,
and anchored in problem solving and
analysis.27 Ultimately, we conducted a
randomized, controlled trial within a
classroom course in which we studied a
new method (case-based collaborative
learning [CBCL]),28 which fused elements
of case-based, problem-based, and teambased learning.29–31 Despite being twice
the size of standard PBL tutorials, CBCL
classes in this study, in which a group of
16 students was subdivided into tables
of 4, were associated with an improved
learning environment and student
achievement.28
Subsequently, the similarly constituted
Task Force on Redesign of the
Preclerkship Curriculum advocated
for recalibration of the balance from
a learning environment with little
accountability to one characterized
by higher expectations and personal/
group accountability for scholarship and
professionalism. The task force endorsed
a core teaching model of trained faculty
1688
working with intermediate-size groups of
learners and pedagogic innovations that
push students to higher levels of Bloom’s
taxonomy.32
We recognized that, while core basic/
population science is needed before the
clinical year, the richness and inspiration
of more advanced science is best suited
to students seasoned by their immersion
in clinical clerkships. Students are more
receptive to advanced topics and to deep,
contextual learning and reinforcement
after encountering these subjects during
their clinical clerkships.
As these considerations coalesced and
our experiment with CBCL succeeded,
the redesign task force called for a
comprehensive review of the entire 4-year
curriculum, unencumbered by traditional
disciplinary boundaries—what we teach,
when we teach it, how we teach, who does
the teaching, and how to assess students.
Considering these guiding questions, the
curriculum reform task force articulated
common curricular themes, objectives,
principles, and values for the 4-year
curriculum (List 1).
Teaching Science
Despite a long-standing tradition
of siloed, discipline-specific courses
(e.g., anatomy, biochemistry,
physiology), course faculty in the
prior curriculum (mostly drawn from
clinical departments) initiated this
reform by advocating and meeting
regularly to plan for integrating
the teaching of science and clinical
medicine across the curriculum. Our
goal was a developmentally appropriate
curriculum anchored in active learning
pedagogy and structured to distinguish
“foundational” and “boundary” science
(Table 2). In the 14-month preclerkship
phase, the acquisition of foundational
concepts in the basic/population
sciences is interleaved midweek with
daylong clinical experiences that
introduce students to the basics of
clinical medicine and permits students
to begin linking basic and clinical
science principles. Teaching in science
courses is delegated primarily to faculty
expert in pedagogy; lectures by “outside”
content experts are limited. For each
course, depth of understanding is
emphasized over quantity of content,
concepts over facts, and the ability
to use knowledge to solve problems
over mere retention of information.
We explicitly distributed the teaching/
learning of basic/population sciences
among preclerkship, clerkship, and
postclerkship phases to align with
students’ developmental learning needs.
Academic Medicine, Vol. 95, No. 11 / November 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
List 1
Objectives, Principles, and Values: Statement of Problem and Rationale for Curriculum Change, Harvard Medical School
Pathways Program
Objectives of the new curriculum:
• Rapid growth in medical knowledge
• Advances in technology that reduce the time needed to access information and increase the range of topics/content that can be obtained within
seconds to minutes
• Mismatch between the current generation of teachers and learners and the implications for pedagogical techniques that engage students
• Increasing need for performance of teams as learners and as providers of care
• Increasing need to support/develop skills and attitudes that are necessary for lifelong learning
• Challenges in achieving integration of knowledge across disciplines
• Challenges of reinforcing cohesive common themes
• Challenges of having an adequately prepared, highly committed group of faculty to support the curriculum
• Increased focus on medical errors and cognitive processing that would diminish errors and improve patient safety
Organizing principles of the new curriculum:
• Inspire students to pursue excellence as competent, curious, caring physicians
• Enhance integration among the basic biological, social, and population sciences and between the basic and clinical sciences while reinforcing the
importance of scientific rigor
• Enhance development of lifelong learning by focusing on student acquisition of content/knowledge, skills, attitudes, and principles of selfreflection via self-study in team-based activities with the assistance of a variety of learning resources that accommodate the heterogeneity of
learning styles
• Enhance development of critical thinking by focusing on processing information to support higher-order cognitive tasks, that is, evaluation,
synthesis, and analysis
• Enhance durable learning and personal accountability with assessment/evaluation activities that enhance learning, that address cumulative
knowledge and skill development, and that are structured as multifaceted exercises to examine content as well as thinking skills with a focus on
application of knowledge to solve problems
• Rely on innovative, effective, and efficient pedagogic models that are student centered and engaging, that model creativity and scholarship, that
renew/reinforce the excitement of learning, that are adaptive and flexible, and that draft off the level of Harvard University-wide curricular foment
captured by the Harvard Initiative in Learning and Teaching
• Raise the level of scientific rigor and clinical relevance
• Promote inquiry and scholarship while providing students with the skills needed to be leaders of teams and in their fields to enable them to catalyze
innovation in all dimensions of medicine by being agents of change
Values embedded within the new curriculum:
• Student centeredness
◦ Preparation for future careers as clinicians, educators, and/or scientists
◦ Active learning
◦ Flexibility to incorporate different learning styles, venues, and class sizes
◦ Liberation of creativity
◦ Fostering and supporting a culture of curiosity and inquiry
◦ Achieving an appropriate balance between a safe learning environment and high expectations for scholarship and professionalism
◦ Creation of assessments that enhance learning
◦ Creation of opportunities for students to develop mastery of material
• Patient centeredness
◦ Early clinical experiences
◦ Longitudinal patient experiences
◦ Supporting and modeling value-added, team-based care
◦ Supporting and modeling humanistic, empathic care
• Commitment to community and society
◦ Respect for and understanding of diverse patient populations
◦ Providing care within a social and system context
• Commitment to excellence
◦ High standards; mastery of material
◦ Performance-based assessment linked to developmental milestones
◦ Uniformity of rigor across small-group learning sites (e.g., tutorials,
clinical sites)
◦ Application of a continuous quality improvement mindset to further refinements of curriculum
(List continues)
Academic Medicine, Vol. 95, No. 11 / November 2020
1689
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
List 1
(Continued)
• Commitment to professionalism
◦ Embedded in all courses and
activities
◦ Mentoring and modeling
• Commitment to lifelong learning
◦ Self-directed learning that incorporates reflection and self-assessment
◦ Developmental, stepwise complexity
◦ Team learning and problem solving
• Appropriate use of technology to enhance the educational experience
◦ Innovative, forward-looking pedagogy
◦ Incorporation of skills/learning labs
◦ Clinical skills center with simulation
◦ Online resources
◦ Question banks
• Partnership between faculty and students
◦ In teaching and learning
◦ In scholarly inquiry
◦ In a culture of intellectual discourse
Based on the trial described above,
faculty implemented CBCL,28 a teaching
approach that emphasizes inductive
reasoning and application of science
concepts to clinical cases. Each entering
class is divided into 4 learning studios
(designed specifically for CBCL
pedagogy) based on academic society,
with roughly 40 students per studio
led by 2 course faculty—either 2 core
teaching faculty or 1 core teaching and
1 content expert; core faculty maintain
a longitudinal connection with the
students over the full course. Within
each learning studio, students work at
4-person tables, a configuration designed
to encourage engagement by all in class
discussion and establish good habits
of teamwork as a fundamental part of
professional identity. Our prior study
of CBCL revealed that students felt they
could “hide” in 8- to 9-student PBL
tutorials but were compelled to engage
in classroom deliberations in 4-person
tables.9 Required, preparatory, directed
self-learning assignments (supplemented
by self-directed learning exercises),
driven by a series of key questions that
all students should be able to answer
(and demonstrate on daily readiness
assessment exercises), prepare students
for CBCL sessions; concepts and
content of classroom and early clinical
experiences are coordinated to enhance
integration and student motivation to
learn. The emphasis is on “why” and
“how” questions that stimulate curiosity
and assess for understanding. Mandatory
attendance supports the value of group
learning in CBCL sessions; with the
significant improvement in the learning
environment accompanying this format
(detailed elsewhere), students have
embraced this requirement.
The Pathways curriculum begins with
foundational basic science (Foundations)
and population science (Essentials of
the Profession, which includes ethics,
epidemiology, health care policy/quality
and safety) courses (see Supplemental
Digital Appendix 1, at http://links.lww.
com/ACADMED/A820) during the first
6 months, equipping students with the
tools and language to navigate organ
systems; an overview of anatomy is
incorporated into Foundations. The
organ-based courses that follow focus on
structure/function and normal/abnormal
processes, reinforce the foundational
Table 2
Approach to Teaching Science in 3 Phases of the Harvard Pathways Curriculuma
Clinical medicine (PCE)
Frontier science
(post-PCE curriculum)
Clinical medical science
Special interest science
Motivation for learning
General biomedical and social/
population sciences
Faculty-directed learning
Patient-directed learning
Self-directed learning
Assessment of learning
Knowledge-based assessments
Knowledge- and performance-based assessments
Independent deliverable projects
Goals for learning
Learning and applying what
is known
Learning and applying what is known
Discovering what is unknown,
developing solutions
Clinical experience
Introduction to clinical care
Yearlong clinical immersion
Specialized clinical opportunities
Attribute
Framework of knowledge
a
Foundational science
(pre-PCE curriculum)
Abbreviation: PCE, principal clinical experience.
These approaches distinguish foundational science, applications of foundational science in the clinical setting,
and frontier or boundary science. Teaching and learning principles are woven through the curriculum, explicitly
acknowledging the developmental maturation of the student.
1690
Academic Medicine, Vol. 95, No. 11 / November 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Figure 1 Organization of the Foundations course of the Harvard Medical School Pathways Program. The preclerkship science courses are integrated
experiences that weave together multiple content areas, interleaving topics (e.g., during the cancer sessions) with planned repetition to enhance
understanding and enduring learning.
sciences (e.g., anatomy prosections are
studied during the organ system courses),
and introduce pharmacological principles
that illuminate pathophysiology.
Moreover, organ systems grouped
to highlight their complementarity
(e.g., cardiovascular–respiratory in
the Homeostasis 1 module) are taught
together, emphasizing integration of
core principles. No course is “owned”
by a basic science department; faculty
from across basic and clinical science
departments collaborated on the content
of the new courses, each of which was
developed from the ground up over a
12-month period.
Planned repetition—in the form of
reassignment of preparatory material
from a prior course or cross-module
integration sessions during a subsequent
course (Figure 1) whereby students revisit
material in a new context—reinforces
learning and facilitates knowledge
transfer. Figure 1 offers an example of this
approach from the Foundations course,
which demonstrates how integrated,
complementary course modules are
taught in parallel but evolve in emphasis
and amplitude (e.g., early emphasis on
anatomy, later emphasis on immunology/
microbiology/pathology), as the course
proceeded.
The 14-month preclerkship curriculum
concludes with a course designed
to consolidate and contextualize
information before entering the wards,
Transition to the Principal Clinical
Experience. Here, science material is
revisited and reinforced from a very
clinical perspective (e.g., limb and neck
anatomy relevant for standard procedures
such as peripheral and central line
placement) and clinical skills are honed
(Supplemental Digital Appendix 1, at
http://links.lww.com/ACADMED/A820).
During the core clinical clerkships, or
Principal Clinical Experience (PCE,33 see
below), students participate in longitudinal
multidisciplinary case conferences that
emphasize integration of basic and clinical
science and reliance on scientific principles
to understand symptoms, physical
findings, and therapeutics.34–37 Clinical
faculty undergo training to transform the
nature of the questions they ask students
at the bedside, building upon the “how”
and “why” questions of the preclerkship
learning studios to promote deep
understanding.38,39 Preparatory materials
(including videos) from preclerkship
courses may be referenced during these
conferences.
After completing the PCE and subsequent
United States Medical Licensing
Examination Step 1 exam (moved to
the beginning of the post-PCE phase
to emphasize the integration of basic
and clinical sciences), students have an
expanded, 19-month post-PCE phase,
during which they continue their basic
Academic Medicine, Vol. 95, No. 11 / November 2020
and population science education, while
further developing their clinical skills and
interests. The preclerkship population
sciences are revisited and reinforced in
the Essentials of the Profession II course,
a required revisit to these foundational
disciplines after a year of ward-based
clinical experiences. A return to the basic
sciences occurs in 2 required Advanced
Integrated Science courses (AISCs) that
students select from 11 options (List 2).
In the AISCs, students explore in-depth
specific scientific topics relevant to their
interests in clinical medicine and to their
scholarly projects.
Instructors in the AISCs, co-taught
by experts in both basic and clinical
List 2
Options for the Advanced Integrated
Science Courses of the Harvard
Medical School Pathways Program
Cancer biology
Regenerative biomedicine
Translational biomedical engineering
Translational pharmacology
Computationally enabled medicine
Human genetics
Immunology
Metabolism, nutrition, and lifestyle medicine
Microbiology and infectious diseases
Global and community health
Neurobiology
1691
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
sciences, encourage students to ask
questions at the interface of biology and
medicine; they explore the boundary of
knowledge rather than the foundation
of accepted knowledge. All AISCs share a
common framework focused on helping
students develop generalizable skills
such as evaluating relevant literature,
identifying unmet clinical needs and
questions suitable for investigation, and
communicating scientific information
to peers and patients. In AISCs, students
engage in an intellectual framework
and skill set they can use both in
their required scholarly projects and
throughout their careers, whether they
pursue research or clinical medicine.
Clinical faculty engaged in preclerkship
and AISC courses as described above
are paid stipends based on contact time
with students to partially offset the loss
of clinical income associated with their
teaching commitment. The medical
school has a promotion pathway for
teaching excellence and leadership,
which is chosen by many of the core
faculty.
Teaching Clinical Skills
From its outset, Pathways has prioritized
teaching clinical skills and integrating
clinical and basic science; this philosophy
is applied across all 4 years—beginning
in the first month and concluding with
a clinical capstone course preceding
graduation.
The Practice of Medicine (POM) course,
HMS’ yearlong preclerkship clinical skills
course, provides clinical preparation
for the PCE. Students learn basic skills
fundamental to the patient–physician
relationship, clinical medicine, and the
care of diverse populations: interviewing
and communication skills, physical
examination, and clinical reasoning.
The POM integrates basic/population
and clinical sciences; clinical skills and
reasoning exercises are coordinated
with classroom experiences in
contemporaneous year-1 preclerkship
science courses (e.g., the physiology of
lung sounds is studied in Homeostasis 1
concomitantly with learning pathological
lung sounds in POM). The course also
focuses on professional development,
self-reflection, and wellness training (the
Developing Physician [TDP] curriculum,
see below).
1692
At each hospital-associated clinical site,
POM relies on core faculty educators
drawn from the clinical faculty, who
teach in small-group interactive
sessions, alternating between inpatient
and ambulatory settings, maintaining
longitudinal relationships with students
throughout the year. Working closely
with clinical preceptors, students also
participate in a yearlong longitudinal
foundational continuity clinic (FCC),
caring for a cohort of patients in a
primary care practice; FCC models the
multidisciplinary, interprofessional
approach to clinical medicine; provides
context for appreciation of the health
care system; and promotes attention to
quality improvement, patient safety, and
health care disparities. An explicit POM
goal is to demonstrate for students the
importance and centrality of primary
care medicine.
Dedication of a full Wednesday each
week (approximately 30% of preclerkship
contact time with faculty) to clinical
medicine in POM underscores the
importance the school places on early
patient experiences, clinical skills, and
formation of students’ professional
identities. Additionally, midweek POM
placement motivates students’ classroom
learning of the basic sciences underlying
their clinical experiences during the
surrounding days of the week.
Following completion of POM and
just before the start of core clerkships,
students participate in the TPCE, as
described above, a 5-week course that
consolidates fundamental clinical and
basic science experiences in preparation
for the PCE, functioning essentially as a
capstone experience for the preclerkship
curriculum.
Details of the PCE, the HMS core
clerkship year, have been published
previously.34–37 Consistent with the
commitment to longitudinal faculty–
student learning in Pathways, students are
assigned to the same clinical site for POM
and PCE. Building on their experiences
in clinical practice from FCC, students
continue this work in their primary care
clerkship in year 2, remaining when
possible with their FCC ambulatory site
and preceptors, offering longitudinal
patient and preceptor experiences that
span 2 full years. The TDP curriculum,
initiated in POM to encourage students
to reflect on their experiences as their
professional identities evolve, continues
throughout the PCE. As a core theme,
humanism is woven through TDP, the
TCPE course, professional development
weeks (PDWs, see below), and a rich
array of elective offerings.
The increased length of the post-PCE
phase, beginning in October of year 3,
provides students with opportunities for
continued growth as clinicians, allowing
them to tailor learning experiences to
individual career “pathways” through a
series of required and elective clinical
experiences, including a mandatory
subinternship in internal medicine.
Step 2 of the National Board of Medical
Examiners examination must be
completed by January of the final year of
medical school.
The culmination of clinical training,
the Clinical Capstone course, offers an
intensive, consolidating clinical experience
just before graduation. The purpose of this
course, distinct from that of “boot camps”
taught elsewhere, is to ensure that students
have achieved all of the programmatic
goals of the curriculum; the capstone is
not intended as a preparatory course for
specific postgraduate training. Taken in
the last 4 months of medical school, this
mandatory subinternship-level course
focuses on complex clinical, diagnostic,
and communication skills expected for a
graduating student.40 The course includes
3 weeks of clinical work embedded
between front- and back-end classroom
experiences. Focusing on assessing
students’ strengths/weaknesses, this
course ensures readiness for graduation
by addressing any outstanding learning
needs and identifies areas for continued
work during residency. The course also
includes didactic sessions on self-care and
management skills to prepare students for
a lifetime of practice.
Assessment, Professional
Development, and Identity
Formation
The assessment framework was designed
to reflect the teaching and educational
principles embedded in the new
curriculum (List 1). Underpinning these
principles was the need to support a
growth (rather than a performance)
mindset16 and to incorporate frequent,
longitudinal, direct observations by
faculty, with multiple opportunities for
formative feedback.
Academic Medicine, Vol. 95, No. 11 / November 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
Principles of assessment
Frequent formative feedback that
reinforces learning occurs during all
courses, clerkships, and electives, and
formal assessments are scheduled
at defined checkpoints, including
summative assessments that confirm
readiness to advance to the next phase of
the curriculum and, ultimately, readiness
to practice upon graduation. Through
three 1-week intersessions during the
preclerkship curriculum (PDWs), faculty
help students learn to seek and initiate
feedback discussions based on selfreflection, inquiry, and active engagement
and to accept constructive feedback as an
important part of their development as
physicians.
Clinical skills and assessment methods
Students’ abilities to perform clinical
skills at a defined level of entrustability
are measured by clerkship evaluations
and formal assessment methods
incorporated into all PCE clerkships:
objective structured clinical exams
(OSCEs), mini-clinical evaluation
exercises, and/or oral examinations.
Grading, remediation, and advancement
Grading in the core clerkships was
shifted to satisfactory/unsatisfactory for
several reasons: to emphasize a growth
mindset and reduce the competitive
nature of grading in the clerkships (as
pass/fail grading had accomplished for
decades in preclerkship courses), avoid
high-stakes evaluations early in medical
school given the shift of clerkships earlier
in year 2, conform with the national
movement toward competency-based
medical education, and accommodate the
complexity of 2 distinct, asynchronous
time points, staggered 6 months apart, for
student entry into the PCE (October for
Pathways students and April for students
in the Harvard-MIT Health Science and
Technology program who have a longer
preclerkship curriculum).41,42
To address the move to a pass/
fail system for core clerkships, we
implemented a novel departmental
summative assessment (DSA) grading
scheme to ensure that students are not
disadvantaged by residency programs
that rely on clerkship grades to screen
applicants. The DSA provides a
comprehensive, longitudinal assessment
of a student’s clinical skills development
and achievement in a field relevant to the
student’s residency application. Based
on a review of students’ performance in
their core clerkship, subinternship(s), and
relevant clinical elective(s), departmental
assessment committees (comprising
faculty from each of the teaching
hospitals) assign DSAs. The impact
of these grading changes on student
learning and the residency application
process is still being studied.
A comprehensive OSCE program spans
the 3 curriculum phases (Supplemental
Digital Appendix 1, at http://links.lww.
com/ACADMED/A820) to provide
longitudinal clinical skills assessment
leading to individualized learning
plans. One of these, a high-stakes
comprehensive examination (passing is a
graduation requirement), is administered
at the beginning of year 4; students must
demonstrate maintenance of skills in the
clinical capstone course during the final 4
months of medical school.
Assessment faculty
Success of the clinical skills assessment
program relies on a highly motivated,
available, and well-trained faculty.
Therefore, we developed a core
assessment faculty of 69 raters who
received formal training on OSCE cases,
checklists, entrustable professional
activity scales, and providing effective
feedback. This assessment cohort has
enhanced OSCE validity by increasing
interrater reliability. The school provides
a small stipend to support the work of
these faculty.
Scholarship
When a scholarly project requirement
was introduced33 during the curriculum
reform initiative of the previous decade,
the objective was to involve each student
in an in-depth faculty-mentored scholarly
partnership (Supplemental Digital
Appendix 1, at http://links.lww.com/
ACADMED/A820). Students consolidate
skills of self-directed learning, critical
thinking, and inquisitiveness; appreciate
how inquiry can be embedded in medical
practice; and recognize how they can
become change agents.
The original scholarly project program
was completed typically during the
summer of year 1 (2 months), before
students had a broad exposure to
medicine and faculty; a growing
Academic Medicine, Vol. 95, No. 11 / November 2020
consensus evolved that students would
be better served with a later research
experience. The structure of the new
curriculum allowed us to achieve the
goal of placing these projects following
the core clinical year. Scholarly projects
initiated after the PCE year, with a
duration of at minimum 4 months,
can be done in an area of inquiry more
relevant to a student’s chosen discipline
and career trajectory. Additionally,
the new structure enabled project and
mentor choices to be informed by a
broader repertoire of first- and secondyear student experiences and faculty
exposures.
Implementation Challenges
Faculty development
Implementation of Pathways required
changes in both faculty and student
engagement. To support the CBCL
teaching format and longitudinal faculty–
student relationships, a core faculty was
created. Initial training efforts focused
on course-specific programs to prepare
faculty before the new curriculum started.
“Just-in-time” intensive training occurred
weeks before the start of each course.
Because the curriculum reform was
faculty conceived, driven, and planned,
skepticism about the utility of change
among faculty engaged in this process
was minimal and subsided further as
excitement over and engagement with the
new pedagogy was followed by positive
student feedback; some faculty more
peripheral to the process had doubts. Core
faculty members, with the exception of
those from the basic science departments
whose job description explicitly includes
teaching, receive stipends for their time
and effort in teaching and assessment.
Nevertheless, the cost of the new
curriculum was essentially unchanged,
that is, budget neutral, from that of the
previous New Pathway; fewer faculty,
more committed to and better trained for
their longitudinal teaching, receive larger
stipends than the higher number of tutors
receiving smaller stipends for shorter
engagements in the prior curriculum.
Student education representatives
To enhance student engagement in the
change process, we partnered with senior
New Pathway students as “curriculum
consultants” during task forces and pilots
of curricular materials throughout the
1693
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
planning stages of Pathways and with
“educational representatives” recruited
from the inaugural Pathways class to
provide real-time feedback on the rollout
of the new curriculum.43,44
Advising
The new pedagogy mandated a greater
focus on individual preparation and
active learning, which was quite different
from what students experienced before
medical school.45 Consequently, we saw
the need to revamp the advising structure
to maximally support students’ academic
and professional needs, mandating
one-on-one meetings with assigned
faculty advisors every 8 weeks during the
preclerkship curriculum. Because of the
association between academic societies
and preclerkship class sections, we were
able to establish closer communication
between society advisors and the teaching
faculty and to monitor regularly students’
academic progress, pace, overall wellbeing, and career advising needs.
Organizing Themes
With this article, we have described
a comprehensive curriculum change
introduced at HMS in 2015 in which
content (what is taught), structure
(when it is taught), pedagogy (how it
is taught), faculty roles (who teaches),
and assessment (did students learn)
were reimagined and reconfigured.
This curriculum overhaul focused on
foundational principles of adult learning
(List 1). The curriculum is committed to
4 key principles described, interwoven
throughout the 4 years of study.
Critical thinking and developmentally
appropriate delivery
Thinking is emphasized over quantity of
content—application of material over
memorization. Although the duration
of the preclerkship curriculum was
truncated, we did not reduce expectations
or “dumb down” the curriculum;
Pathways is more rigorous than its
predecessor. The intent was to expose
students to the important foundational
sciences progressively over time, before,
during, and after their clinical clerkships,
aligning teaching basic biological/
population sciences with the time when
students are most developmentally
ready to learn them in coordination
with clinical medicine. We consider the
creation of a core faculty, expert in both
1694
the science of medicine and the pedagogy
essential to learning, a critical element in
the success of this approach.
Integration
The close work of course directors in the
design of the new curriculum provided
multiple opportunities for horizontal
and vertical content integration. The
actual process of creating an integrated
curriculum was itself an important
factor in interleaving and reinforcing
content—course directors emerged
from the planning process knowing
exactly what everyone else was teaching.
Content and concepts are now integrated
across disciplines continuously, within
and between courses as well as among
basic, clinical, and population sciences.
Required advanced science courses in
the post-PCE phase make explicit the
importance of science to the practice of
medicine over an entire career.
Acknowledgments: The authors acknowledge
the contributions of additional members of
the Pathways Writing Group to this article: Tod
Griswold, MD, Mary Mullen, MD, Fidencio
Saldana, MD, Katharine K. Treadway, MD, and
Susan Farrell, MD.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable
R.M. Schwartzstein is professor of medicine,
Department of Medicine, Beth Israel Deaconess
Medical Center and Harvard Medical School, Boston,
Massachusetts.
J.L. Dienstag is professor of medicine, Department
of Medicine, Massachusetts General Hospital and
Harvard Medical School, Boston, Massachusetts.
R.W. King is professor of cell biology, Harvard
Medical School, Boston, Massachusetts.
Student engagement: Focus on the
learner
Engagement of the student is critical
for learning to occur. Whether in the
classroom or the clinical arena, through
the assignments we provide and the way
we ask questions, the goal is to support
curiosity and ensure that students are
engaged fully in the learning process.
Essentially, we concentrated at every step
on shifting the teacher–learner paradigm
to focus not on what and how we teach
but on what and how students learn.
Professional identify formation
The process of becoming a doctor
is arduous, and the transition in the
approach to learning from college
student to doctor must be recognized
and structured carefully to meet the
developmental level of the learner.
Assignments in our CBCL format assist
students in developing the skills and
habits of mind necessary for self-directed
learning. The initiation of primary care
experience in the first month of medical
school, with graduated responsibility
and autonomy through each phase of
the curriculum, motivates students by
imbuing the curriculum with clinical
relevance.
By deliberate design, Pathways employs
the science of learning to educate and
prepare physicians for the 21st century.
Ultimately, the whole is greater than
the sum of its parts—each piece (from
core principles to enabling policies) is
positioned strategically to yield a student
prepared at commencement for a career
that will be characterized by change and
challenge.
B.S. Chang is associate professor of neurology,
Beth Israel Deaconess Medical Center and Harvard
Medical School, Boston, Massachusetts.
J.G. Flanagan is professor of cell biology, Harvard
Medical School, Boston, Massachusetts.
H.C. Besche is instructor in cell biology, Harvard
Medical School, Boston, Massachusetts.
M.P. Hoenig is associate professor of medicine,
Beth Israel Deaconess Medical Center and Harvard
Medical School, Boston, Massachusetts.
E.M. Miloslavsky is assistant professor of
medicine, Massachusetts General Hospital and
Harvard Medical School, Boston, Massachusetts.
K.M. Atkins is assistant professor of obstetrics,
gynecology and reproductive biology, Beth Israel
Deaconess Medical Center and Harvard Medical
School, Boston, Massachusetts.
A. Puig is associate professor of medicine,
Massachusetts General Hospital and Harvard Medical
School, Boston, Massachusetts.
B.A. Cockrill is associate professor of medicine,
Brigham and Women’s Hospital and Harvard Medical
School, Boston, Massachusetts.
K.A. Wittels is assistant professor of emergency
medicine, Brigham and Women’s Hospital and
Harvard Medical School, Boston, Massachusetts.
J.L. Dalrymple is associate professor of obstetrics,
gynecology and reproductive biology, Beth Israel
Deaconess Medical Center and Harvard Medical
School, Boston, Massachusetts.
H. Gooding is assistant professor of pediatrics, Emory
University School of Medicine, Atlanta, Georgia.
D.A. Hirsh is associate professor of medicine,
Cambridge Health Alliance and Harvard Medical
School, Boston, Massachusetts.
E.K. Alexander is professor of medicine, Brigham
and Women’s Hospital and Harvard Medical School,
Boston, Massachusetts.
Academic Medicine, Vol. 95, No. 11 / November 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Article
S.B. Fazio is professor of medicine, Beth Israel
Deaconess Medical Center and Harvard Medical
School, Boston, Massachusetts.
E.M. Hundert is dean for medical education
and professor in residence of global health and
social medicine at Harvard Medical School, Boston,
Massachusetts.
References
1 Flexner A. Medical Education in the United
States and Canada: A Report to the
Carnegie Foundation for the Advancement
of Teaching. Bull. No. 4. Boston, MA:
Updyke; 1910.
2 Christakis NA. The similarity and frequency
of proposals to reform US medical education.
Constant concerns. JAMA. 1995;274:706–
711.
3 Irby DM, Cooke M, O’Brien BC. Calls
for reform of medical education by the
Carnegie Foundation for the Advancement
of Teaching: 1910 and 2010. Acad Med.
2010;85:220–227.
4 Cooke M, Irby DM, O’Brien BC. Educating
Physicians: A Call for Reform of Medical
School and Residency. San Francisco, CA:
Jossey-Bass; 2010.
5 Lucey CR. Medical education: Part of the
problem and part of the solution. JAMA
Intern Med. 2013;173:1639–1643.
6 Kulasegaram K, Mylopoulos M, Tonin P, et
al. The alignment imperative in curriculum
renewal. Med Teach. 2018;40:443–448.
7 Heiman HL, O’Brien CL, Curry RH, et
al. Description and early outcomes of a
comprehensive curriculum redesign at the
Northwestern University Feinberg School of
Medicine. Acad Med. 2018;93:593–599.
8 Fischel JE, Olvet DM, Iuli RJ, Lu WH,
Chandran L. Curriculum reform and
evolution: Innovative content and processes
at one U.S. medical school. Med Teach.
2018:1–8.
9 Stevens CD. Repeal and replace? A note
of caution for medical school curriculum
reformers. Acad Med. 2018;93:1425–1427.
10 Tosteson DC. Learning in medicine. N Engl J
Med. 1979;301:690–694.
11 Tosteson DC. Alan Gregg Memorial Lecture.
Science, medicine, and education. J Med
Educ. 1981;56:8–15.
12 Tosteson DC. New pathways for medical
education. JAMA. 1991;265:1022–1023.
13 Tosteson DC, Adelstein SJ, Carver ST. New
pathways to medical education: Learning to
learn at Harvard Medical School. Cambridge,
MA: Harvard University Press; 1994.
14 Friedman CP, Donaldson KM, Vantsevich
AV. Educating medical students in the era
of ubiquitous information. Med Teach.
2016;38:504–509.
15 Roberts DH, Newman LR, Schwartzstein
RM. Twelve tips for facilitating Millennials’
learning. Med Teach. 2012;34:274–278.
16 Dwek CS. Mindset: The New Psychology of
Success: How We Can Learn to Fulfill Our
Potential. New York, NY: Ballantine Books;
2016.
17 Cepeda NJ, Vul E, Rohrer D, Wixted JT,
Pashler H. Spacing effects in learning: A
temporal ridgeline of optimal retention.
Psychol Sci. 2008;19:1095–1102.
18 Kahneman D. Thinking, Fast and Slow. New
York, NY: Farrar, Straus and Giroux; 2013.
19 Mayer RE. Applying the science of learning to
medical education. Med Educ. 2010;44:543–549.
20 McGaghie WC. Mastery learning: It is
time for medical education to join the 21st
century. Acad Med. 2015;90:1438–1441.
21 McGaghie WC, Fisichella PM. The science of
learning and medical education. Med Educ.
2014;48:106–108.
22 Crouch CH, Mazur E. Peer instruction: Ten
years of experience and results. Am J Physics.
2001;69:970–977.
23 Mazur E. Farewell, lecture? Science.
2009;292:50–51.
24 Schwartzstein RM, Roberts DH. Saying
goodbye to lectures in medical school—
Paradigm shift or passing fad? N Engl J Med.
2017;377:605–607.
25 Lorenzo M, Crouch CH, Mazur E. Reducing
the gender gap in the physics classroom. Am
J Physics. 2006;74:118–122.
26 Gooding HC, Mann K, Armstrong E. Twelve
tips for applying the science of learning to
health professions education. Med Teach.
2017;39:26–31.
27 Harasym PH, Tsai TC, Hemmati P. Current
trends in developing medical students’
critical thinking abilities. Kaohsiung J Med
Sci. 2008;24:341–355.
28 Krupat E, Richards JB, Sullivan AM, Fleenor
TJ Jr, Schwartzstein RM. Assessing the
effectiveness of case-based collaborative
learning via randomized controlled trial.
Acad Med. 2016;91:723–729.
29 Haidet P, O’Malley KJ, Richards B. An initial
experience with “team learning” in medical
education. Acad Med. 2002;77:40–44.
30 Koles PG, Stolfi A, Borges NJ, Nelson S,
Parmelee DX. The impact of team-based
learning on medical students’ academic
performance. Acad Med. 2010;85:1739–1745.
31 Thompson BM, Schneider VF, Haidet P, et al.
Team-based learning at ten medical schools:
Two years later. Med Educ. 2007;41:250–257.
32 Bloom BS, Englehart MD, Furst EJ, Hill WH,
Krathwohl DR. Taxonomy of educational
objectives: The classification of educational
goals. Handbook I: Cognitive Domain. New
York, NY: David McKay Company; 1956.
33 Dienstag JL. Evolution of the New Pathway
curriculum at Harvard Medical School: The
Academic Medicine, Vol. 95, No. 11 / November 2020
34
35
36
37
38
39
40
41
42
43
44
45
new integrated curriculum. Perspect Biol
Med. 2011;54:36–54.
Hirsh DA, Ogur B, Thibault GE, Cox M.
“Continuity” as an organizing principle for
clinical education reform. N Engl J Med.
2007;356:858–866.
Ogur B, Hirsh D, Krupat E, Bor D. The
Harvard Medical School-Cambridge
integrated clerkship: An innovative model of
clinical education. Acad Med. 2007;82:
397–404.
Hirsh D, Gaufberg E, Ogur B, et al.
Educational outcomes of the Harvard
Medical School–Cambridge integrated
clerkship: A way forward for medical
education. Acad Med. 2012;87:
643–650.
Bell SK, Krupat E, Fazio SB, Roberts DH,
Schwartzstein RM. Longitudinal pedagogy:
A successful response to the fragmentation
of the third-year medical student
clerkship experience. Acad Med.
2008;83:467–475.
Hayes MM, Chatterjee S, Schwartzstein
RM. Critical thinking in critical care: Five
strategies to improve teaching and learning
in the intensive care unit. Ann Am Thorac
Soc. 2017;14:569–575.
Royce CS, Hayes MM, Schwartzstein RM.
Teaching critical thinking: A case for
instruction in cognitive biases to reduce
diagnostic errors and improve patient safety.
Acad Med. 2019;94:187–194.
Pereira AG, Harrell HE, Weissman A, Smith
CD, Dupras D, Kane GC. Important skills
for internship and the fourth-year medical
school courses to acquire them: A national
survey of internal medicine residents. Acad
Med. 2016;91:821–826.
Wilkerson L, Abelmann WH. Producing
physician-scientists: A survey of graduates
from the Harvard–MIT Program in Health
Sciences and Technology. Acad Med.
1993;68:214–218.
Abelmann WH, Nave BD, Wilkerson
L. Generation of physician–scientists
manpower: A follow-up study of the first 294
graduates of the Harvard–MIT Program of
Health Science and Technology. J Invest Med.
1997;45:272–275.
Anderson J, Calahan CF, Gooding H.
Applying design thinking to curriculum
reform. Acad Med. 2017;92:427.
Scott KW, Callahan DG, Chen JJ, et al.
Fostering student-faculty partnerships for
continuous curricular improvement in
undergraduate medical education. Acad Med.
2019;94:996–1001.
Premkumar K, Pahwa P, Banerjee A, Baptiste
K, Bhatt H, Lim HJ. Does medical training
promote or deter self-directed learning? A
longitudinal mixed-methods study. Acad
Med. 2013;88:1754–1764.
1695
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.