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Student Notebook

Curriculum vivum

By Kristen Yurkerwich

For the most part, we DMS students are pleased with our medical education. According to a recent survey conducted by the Association of American Medical Colleges, more than 50% of Dartmouth M.D. graduates were "very satisfied" with their medical education, compared to only 35%ofmedical school graduates nationwide. DMS's relatively small enrollment of 300-some M.D. students and our 2:1 faculty-to-student ratio foster strong student-faculty connections. These factors surely have a lot to do with our above-average student satisfaction. But as happy asmany of us are, we know there are some things that could be even better.

Timing: Take, for instance, the timing of clinical clerkships and subspecialty electives. In surveys of exiting DMS students, one of the most consistent suggestions for improvement has been to allow students to take subspecialty electives sooner. Dartmouth, like most U.S. medical schools, dedicates the first two years of its curriculum to classroom work on the basic biomedical sciences, the normal structure and function of the human body, and the mechanisms of disease. Students spend most of the final two years in hospital and office settings, taking required clinical clerkships as well as electives. Schools differ in how much time they dedicate to required clerkships. There is no magic formula scripted by the Liaison Committee on Medical Education, the accrediting authority for medical schools. Each institution's medical education committee—usually chaired by an experienced facultymember who is familiar with the history of the school and the needs of its students—makes recommendations about scheduling and other curricular matters for that particular school.

DMS is one of the few U.S. medical schools to devote equal time, about seven and a half weeks, to each of the six required third-year clerkships: internal medicine, surgery, family medicine, psychiatry, pediatrics, and obstetrics and gynecology. Most other schools vary the amount of time for the core clerkships, with greater emphasis on surgery, medicine, and pediatrics; this leaves some time in year three for specialty electives. At DMS, however, the only way a student can take an elective in year three is to delay a required clerkship until year four. But such an arrangement can be difficult to schedule.

Nuances: The nuances of coordinating a high-quality, uniform medical education—for a class of more than 70 students in a fast-paced clinical setting—pose a tremendous challenge. Deans must coordinate the complex schedule with each individual clerkship director. And the clerkship directors, whilemaintaining full-fledged practices themselves, must organize preceptors to supervise as many as 14 students at a time during each of the year's six clerkship blocks. For clerkships that are outpatient-based—such as family medicine, outpatient pediatrics, and a portion of obstetrics and gynecology—it can be hard to find preceptors who are available throughout the year.

DMS is known nationally for providing an excellent primary-care education. The fact that students' time is weighted toward primary care surely contributes to this reputation. But the extra time in primary- care environments has some tradeoffs. For DMS students interested in specialties such as anesthesiology, radiology, and emergency medicine, it is sometimes a struggle to schedule elective rotations in these areas and gather appropriate letters of recommendation prior to the residency application deadline, which is early in the fourth year. As a result, many DMS students have asked that a block of elective time be built into the third year so they're not at a disadvantage compared to students at other top U.S. medical schools.

Schedule: In response to these requests from students for elective time during the third year, the medical education committee has been exploring options and is considering recommendations for a new schedule. Any proposed change to the third-year schedule will be complicated and must factor in the concerns of students, clerkship directors, department chairs, and other teaching faculty.

One concern is that the primary-care disciplines may suffer, as the time allotted to family medicine and psychiatry would likely be reduced. Yet even students headed for primary-care residencies say there is an advantage to having elective time in year three, because they have an opportunity to see more rare diseases in subspecialty clinics than in a primary-care clerkship. For example, a student on a familymedicine rotation might see only one patient with a thyroid nodule in the course of a month. But a student shadowing a surgical oncologist could, in one day, examine, work up, and learn from several patients with thyroid cancer. Such exposure to disease benefits students regardless of the specialty they eventually choose. For those going into primary care, subspecialty electives might provide their only chance to learn from high concentrations of rare diseases.

One thing is certain—at DMS, faculty and students work together to tackle challenging issues like these. Each class has two elected representatives who serve as votingmembers of the medical education committee. They report back to the Student Government and keep the student body informed. DMS is a remarkable place, where student opinion counts and where we continually work together with faculty and administrators to improve our medical education.

The Student Notebook essay offers insight into the activities or opinions of students and trainees. A DMS '09, Kristen Yurkerwich was president of the Medical School Student Government in 2007-08. Just before this issue went to press, the DMS Administration endorsed several proposed changes to the curriculum, including a plan that would allow elective time in year three without requiring a delay in a major clerkship. The details are being worked out and the changes may be implemented as early as June 2009.

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