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Stanford medical major rule says students must pick path early

Critics say asking first-year students to choose a scholarly concentration points them toward specialties too soon.

By Myrle Croasdale, amednews staff. Dec. 15, 2003.

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Steve Ortiz, a first-year medical student at California's Stanford University School of Medicine, is already thinking seriously about a career in organ transplantation. While most med students spend their first year deep in basic science, Ortiz is also working in a transplant surgeon's lab, and he'll be picking a major. Immunology is his first choice, since the immune system's response is crucial to the success of transplants.

"If all goes well, I'm well on my way to getting into a surgical residency when the time comes," Ortiz said.

Stanford is the first U.S. medical school to require that all of its students choose a scholarly concentration by the spring of their first year.

Stanford officials believe the concentrations will allow students to develop an expertise in one particular area within the broad range of subjects required of all doctors in training. Proponents see it as a way for tomorrow's physician leaders to develop analytical and investigative skills.

Critics, however, say the structure asks students to specialize too soon. They say if such a concept spreads -- Harvard is considering it -- the trend away from primary care among medical graduates could be accelerated and the nation's health jeopardized.

Stanford's administrators and faculty, however, aren't making that leap.

"By no means does a scholarly concentration make them a specialist," said Oscar Salvatierra, MD, director of the Pediatric Kidney Transplantation Program at Stanford and chair of a faculty committee helping shape the new curriculum, which Stanford debuted this year.

"The key to this whole thing is developing independence and a passion for learning," he said. "These students will be mentored better than they've been mentored before."

Malcolm Cox, MD, dean for medical education at Harvard Medical School, said the school is seriously considering creating concentrations for its medical students as it overhauls its curriculum.

He said selecting a major may look like asking students to subspecialize, but this is not the intent.

"By giving students the opportunity to pursue something in depth, we allow them to develop analytical skills," Dr. Cox said. "It's not the topic but the process of learning how to analyze a problem."

He believes all medical schools could benefit from offering students the chance to delve into a single field.

"We need to enhance the problem-solving ability in the modern physician," Dr. Cox said. "We would not be serving the public well if we did not consider this seriously."

Providing structure

Patricia Cross, PhD, Stanford's associate dean for medical students, said scholarly concentrations give structure to what students already are doing. Some 70% of Stanford's medical students had been adding a fifth year to their studies to do independent projects. Now they'll have formal support from faculty in their major.

The concentrations fit into Stanford's new curriculum, which integrates research and clinical work through the four years of medical school instead of segregating basic science to the first two years and clinical training to the last two. Students also have the option of extending their schooling to five years to do more work in their majors. They may also change majors, if they do it early.

This year's concentration options are: bioengineering, biomedical ethics and medical humanities, biomedical informatics, community health and public service, health services and policy research, immunology, the molecular basis of medicine, and women's health and sex-based research. Future additions may include: international health, imaging, infectious disease, cardiovascular medicine and clinical investigation.

Having medical students pick majors may work at schools geared toward producing subspecialists, researchers or physician leaders, say critics, but not all schools should do it.

Hal Williamson, MD, chair of the department of family and community medicine at the University of Missouri, Columbia, School of Medicine, isn't buying into the concept.

"It feels to me like making people make a commitment a little early," he said. "In my opinion it is too soon."

Most medical students change their choice of discipline at least once or twice, he said.

"The process of having to commit to an area during their first year will either frustrate students if they end up changing their minds, or [the school] will be attracting students who already know what they want," Dr. Williamson said.

It's possible that schools like Stanford and Harvard attract only applicants who have a specific medical career in mind, Dr. Williamson said. But he has found that most med students are fresh out of college and have little knowledge about various fields.

"In terms of primary care, we know a majority of students entering public medical school say they want this, and then only a small minority come out and actually do it," he said.

Students like to keep their options open, he said, even during residency. At Missouri, which is known for its primary care program, family medicine residents are asked to choose between rural and urban tracks.

"We have a hard time getting residents to commit," he said. "They can't say, 'I know I want to be a rural physician,' 'I want to be an urban doctor,' or even, 'I want to deliver babies.' "

Questions about the public good

The concept of medical school majors also troubles Albert Miller, MD, a cardiologist and member of the AMA's Senior Physicians Group.

"This is the way to create experts in molecular medicine, leaders in medicine," Dr. Miller said. "This is not the way to create sophisticated clinical physicians."

Duplication of the program at other schools could be bad for the nation's overall health.

"If other schools chase this bandwagon, in the long run that will hurt the practice of medicine," he said. "We're having a hard time creating good, well-rounded physicians. This doesn't sound like the way to do that."

Richard Cooper, MD, director of the Institute for Health Policy at the Medical College of Wisconsin in Milwaukee, sees it differently.

"Stanford and Harvard are simply responding to the reality of who their students are and how best to meet their needs," he said, "But it is also an acknowledgment that primary care as it was pushed in the 1990s is no longer the high priority that it once was -- another reality."

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