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.