Revival of the M.D. Degree

AFTER a lapse of 56 years, the Dartmouth Medical School will return to the full M.D. course of study in September. The new program, taking only three years instead of the traditional four, is designed to serve as a test model for shortening and modernizing medical education as one means of meeting the nation's urgent need for more physicians. The program also includes features aimed at improving delivery of medical service in northern New England.

Along with the formal announcement of the new program, Dean Carleton B. Chapman disclosed that a new Department of Surgery was being established and that Dr. Richard C. Karl of the Cornell University Medical College had been named to serve as its chairman. Dr. Karl's appointment virtually completes the academic reorganization necessary for the restoration of the M.D. degree at Dartmouth, the nation's fourth oldest medical school, founded in 1797.

The Medical School conferred the M.D. degree until 1914 when, in the wake of the Flexner Report, the Dartmouth Trustees decided the School did not have access to adequate clinical facilities to keep pace with the changing patterns of medical education. From then until now Dartmouth has concentrated on providing a first-class two-year program in the basic medical sciences, and its graduates have been completing their studies at' other medical schools, notably Harvard.

The next milestone in the School's evolution came in 1957 when, in response to a survey conducted by representatives of the Council of Medical Education and the Association of American Medical Colleges, the Dartmouth Trustees reaffirmed the prior judgment of College authorities that the curriculum be revitalized along highly progressive lines. There followed the virtual refounding of the two-year curnculum, which led in due course to the decision to institute a streamlined M.D. program.

The new three-year medical curriculum, emphasizing refinement of traditional course content while reducing the time requirements, is combined with options to pursue non-medical graduate studies at Dartmouth, enabling students to broaden the base of their training. Some medical students will be accepted for the new M.D. program after three years of college, thus further reducing the combined time of college and medical school from eight to six years.

The clinical phase of the new M.D. program will center on the newly expanded Mary Hitchcock Memorial Hospital, now a 450-bed regional referral and teaching hospital serving a primary area of 600,000 persons in New Hampshire, Vermont, and Maine. A 200-bed Veterans Administration Hospital in White River Junction and smaller community hospitals in the Upper Connecticut River Valley comprise other components of this pioneering system of medical education and service. A strong Division of Community Medicine is being developed to foster the necessary working relationship between the Dartmouth-Hitchcock Medical Center and community hospitals, both for undergraduate and continuing medical educa- tion.

The new curriculum, recognizing the totality of both students' and patients' lives, will encourage interdisciplinary study and care. For example, the traditionally separate Departments of Obstetrics-Gynecology and Pediatrics will be combined into a single Department of Maternal and Child Health to promote a continuum of service. With the new curriculum reinforcing the teaching role of Mary Hitchcock Hospital, special stress will also be placed on further development of the quality and scope of rural medicine.

Among the 53 students to be admitted to the Dartmouth Medical School next September, sixteen will be accepted as candidates for the M.D. degree, to be awarded in June 1973. When total conversion is completed in 1974 or 1975, the student body will have been increased from 106 to 192.

Although relatively small in scale, the Dartmouth Plan for Medical Education is envisioned as a "pilot program" that may provide solutions to such varied national health care problems as shortening the training time and increasing the flow of physicians, lowering the cost of medical education, improving the delivery of health services, and helping to alleviate the afflictions of rural poverty.

Charged with the task of guiding the Dartmouth Medical School in its new mission is Dr. Chapman, an internationally known research cardiologist and former president of the American Heart Association, who assumed the deanship in 1966. Discussing the new three-year M.D. program at a New York press conference, Dr. Chapman said, "Despite the huge sums spent on health education, our nation has to date created no adequate mechanism - in or out of the medical schools - for developing a health system that can meet our growing need. The nation needs more health personnel, including physicians, and the medical schools must supply them. But increasing the number of physicians will not, by itself, solve the health crisis. For this reason, the medical schools must participate in designing new means of financing and delivering health services. The 'revolution of rising expectations,' afoot in the United States as elsewhere, adds urgency to the problem.

"As the medical schools become more actively involved in these vital activities in order to fulfill their obligation to the community more fully, they must, at the same time, manage to maintain both high educational standards and a climate cordial to medical scholarship.

"Dartmouth Medical School, taking advantage of its small, relatively manageable size and association with Dartmouth College, proposes an answer to these important questions. Fortunately, Dartmouth Medical School draws on a distinguished heritage of experience and scholarship in medical education. Yet because the School has operated only the two-year basic medical science program for 56 years, it is not locked into the traditional four-year academic structure and can more readily chart new courses in medical education.

"Finally, development of the Dartmouth Plan has been influenced by the desire of the medical faculty to shorten the curriculum as it improves its quality, and to alter the sequence of traditional offerings in order to render them more relevant to present need in the health area."

In order to realize the aims defined by Dean Chapman the new curriculum at the Medical School has broken with traditional educational patterns in both the sequence and the content of courses so as to meet modern needs and to provide the basis for later, more specialized training. It requires that the traditional division between the premedical, preclinical, and clinical compartments begin to yield to a continuous and coordinated educational experience beginning in college and ending with the internship.

Principal academic features of the plan are:

Admission to medical school after three years of college training for many students, recognizing the dramatic advances in the quality and scope of secondary education and the possibility of shortening the student's undergraduate period without impairing its content.

Adoption of an eleven-month academic year, a long-overdue move that will permit more efficient use of facilities and better design of the student's learning exposure.

Designation of blocks of unassigned time in the first and second years (up to one half of the total teaching hours) for special independent study in subjects not traditionally a part of the medical curriculum.

Provision of a variety of training sequences to accommodate students with different goals, talents, and preferences.

An open, integrated clerkship at the Dartmouth-Hitchcock Medical Center in the third year.

Under consideration is a fourthyear internship under direction of the Medical School.

Concern for the human factor, be it student or patient, pervades the curriculum reform at the Medical School. In announcing the appointment of the chairman of the new Surgery Department, Dean Chapman emphasized Dr. Karl's "ability to maintain the highest standards of patient care while at the same time pursuing his teaching and research functions. His leadership assures the development of a Department of Surgery where teaching and patient care will reinforce each other to the benefit of both." Dr. Karl, whose career encompasses both academic medicine and private practice, is Associate Professor of Surgery at the Cornell University Medical College. Since 1967 he has been at the North Shore Hospital, Manhasset, Long Island, where he inaugurated an academic teaching service in surgery.

Establishment of the new Department of Surgery at Dartmouth has been significantly advanced by a $200,000 grant from the Richard King Mellon Charitable Trusts. It is the second grant in a year from the Pittsburgh-based foundation in support of the new M.D. program. The John A. McCarthy Foundation also participated in creation of the new Department of Surgery with a $50,000 grant.

In support of the Medical School's educational program, the Mellon Trusts earlier made a grant of $250,000. Other major help in this category has come jointly from the Vivian Beaumont Allen Foundation and three graduates of the College. The Foundation's grant of $650,000 and matching gifts of $50,000 each from William H. Morton '32 and Roald A. Morton '34 have endowed the Nathan Smith Professorship of Medicine. For scholarship support, a grant of $100,000 from the Vivian Beaumont Allen Foundation has been matched by a gift of $103,500 from Ralph Falk 2nd '42.

Currently pledged for the purpose of a new medical research building is $3,516,251. Three major gifts in this category are $1.75 million from Mr. and Mrs. Martin J. Remsen '14; $1.5 million from Mr. and Mrs. Foster G. McGaw in memory of James D. Vail '20, Mrs. McGaw's first husband; and $250,000 from James C. Chilcott '20.

Some Curriculum Details

The so-called Dartmouth Plan for Medical Education holds to the central premise that it is the business of the medical school to train a student so that he can move either into research and academic pursuits or into medical practice. When fully developed it will produce a graduate who is broadly trained and can proceed with equal facility into a medical specialty, a research calling, or new opportunities in community medicine.

By its flexible and regional nature the Dartmouth curriculum also provides concurrent opportunities for the continuing education of practicing physicians. A two-way closed circuit television hook-up with Claremont General Hospital, thirty miles away, introduced in 1967 by the Department of Psychiatry for interviewing patients experiencing emotional crises, has been widely used for diagnosis and consultation in surgery and medical services.

One key feature of the new curriculum is the reduction in formal, scheduled classroom hours and concomitant utilization of independent studies. In the first two years, there will be three half-days a week of unassigned time during which the student may engage in medical research, non-medical graduate studies, or tutorial guidance if he is experiencing academic difficulties.

The Medical School's close association with the College and its graduate professional schools would enable a hypothetical M.D. candidate to study medical economics at the Tuck School, assist in the design development of a new blood pressure measuring device at the Thayer School, or enroll in a graduate course in the Mathematics Department of the College.

The first year of the new medical program will emphasize the basic medical sciences, similar to the core curriculums introduced by other medical schools. The first half of the second year offers an interdisciplinary phase in which the student becomes acquainted with the principles of clinical science, the mechanism of disease and its relationship to the basic-science material already presented. A strong Department of Psychiatry intercedes at key points to teach the psychological and social aspects of illness and their relevance to good patient care. During the latter half of the second year, the student will be introduced to clinical diagnosis one half-day a week.

At the end of his second year the student will choose between a basicscience or a clinical route. Those electing the former will receive some clinical training, but the emphasis will be on the basic medical sciences so they can proceed without undue loss of time to specialized work leading to the Ph.D. degree.

Those choosing careers as a practicing physician will proceed during the third year to an open clerkship - working with patients under close supervision which continues the dual exposure to basic medical science and clinical situations. Some students who wish to follow careers in basic science may elect to take the clerkship year and acquire the M.D. degree before entering full-time basic-science training. Students who plan to enter clinical medicine may elect an additional year of concentrated study of a basic science after the second year and before the clerkship years.

In the integrated medical-surgical clerkship during the third and final Medical School year, each student will be assigned the role of a general physician to selected patients. Working under the supervision of teaching teams of faculty members, resident physicians, and interns, the students will study the conditions and needs of their patients in detail, and will make a comprehensive presentation to the teaching team concerning measures to be taken for each patient's care.

Although some of the latter-stage curriculum is still under faculty study, the revised basic-science curriculum was introduced in September 1968. It has been enthusiastically received by students, even though they were unable to enroll in the three-year M.D. program.

Maximum use of audio-visual aids has been integrated into the basic-science curriculum. Students not concentrating in surgery no longer spend arduous classroom time dissecting cadavers. Instead, any hour of the day or night, using a self-teaching viewer, they can review full-color films depicting the dissection of a specific area of the body. Similarly, a surgical resident or practicing physician can activate a refresher course, simply by selecting the appropriate film cartridge. A self-teaching laboratory will be part of a new medical-sciences building, scheduled for opening in mid-1973. It will double the floor space now available.

Dean Carleton B. Chapman of the Medical School, who will direct the new Dartmouth Plan of Medical Education, of which he has been the chief architect.

Aerial view of the Medical School plant, showing its close relation to the Hitchcock Hospital (lower right).