Medical schools across the country are offering courses that take students out of large lectures and turn them from doodlers into detectives following a model designed by Harvard Medical School (HMS) over a decade ago.

HMS's New Pathway program is perhaps the most comprehensive example of "problem-based learning"-a philosophy of teaching that has students work in small groups to solve specific clinical "cases."

HMS assembled this program in the mid-80s and has used it for about 60 percent of its instruction since.

Now, more and more medical schools are using similar programs-encouraged by what HMS officials say is a high rate of satisfaction among students.

According to HMS Dean for Medical Education Daniel D. Federman '49, HMS developed the new curriculum in the early 80s by combining elements of problems-based learning programs at other schools.

"We did not invent a single element, but we did put together the whole package," Federman says.

The result was named the New Pathway tested in 1985 and 1986 and set in place permanently in 1987.

Learning by Doing

Students who learn medicine from the New Pathway take an active role in their own education, Federman says.

A traditional medical school has students spend two years in lecture courses and then two years in clinical training during which students follow doctors in area "teaching hospitals."

In the New Pathway program, the first two years are spent predominantly in eight-person groups headed by a tutor.

Within these groups, the students are presented with a "case"-a hypothetical patient with a disease, often modeled on real patients. The students investigate these cases by looking up medical texts on their own and discussing the results of their research in class.

"The purpose is not to diagnose or learn to treat the patient, but to understand the science... that underlies the problem," Federman says.

For instance, given the case of a patient with lung cancer complaining of a cough, students must learn how cancer develops and spreads in cells in order to understand the biology behind the disease.

About 60 percent of HMS' first two years is taught in small-group tutorials, with the other 40 percent being done in traditional lecture courses. But Federman says that students spend 80 percent of their studying time on their problem based learning courses.

Officials praise the method because it allows students watch a problem unfold from Monday to Friday and take information from several different clinical areas at once.

"Students do a lot of foraging on their own," Federman says.

"The real innovation of the New Pathway is that the biological sciences are taught in a tutorial fashion rather than a lecture fashion," says Byron J. Good, professor of medical anthropology at HMS.

Happy Students, Happy Doctors

According to Good, who interviewed students from both the traditional and the New Pathway over a four-year period, students using problem based learning have generally had more positive medical school experiences.

"It was obvious that [the experiences] were different," Good says. “People found the New Pathway more fun."

By allowing students to spend time looking up their articles for themselves instead of reading textbooks, professors say the curriculum keeps students active.

"They are thinking and talking every-day instead of sitting there listening," Federman says.

"[The students] felt that they learned the material in a way that was close to clinical cases," Good says. "It's more practical."

Federman also said he believes Harvard students enjoy learning through the New Pathway.

"Our students are much happier in medical school now than they were with our previous method," Federman says. "I don't feel it; I know it."

Introduced in the New Pathway program was also a class called the Patient/Doctor course, which introduces issues such as ethics, culture, race, gender and economics and shows students how they relate to medicine.

"It involves a deep respect for the moral and professional responsibilities of being a doctor," Federman says. "The patient/doctor course and problem-based learning are focused on sick persons."

By combining realistic case studies and moral education, Good says the New Pathway helps students understand a disease's effect on patients' worlds, not just their bodies.

"The patient's illness rather than just the disease becomes important," Good says.

Other Alternatives

Most schools use only some problem based learning courses and are reluctant to make such an extreme change in their traditional styles. Emory Medical School Professor Jonas A. Shulman says that he was highly in favor of the curriculum at first, but then saw some flaws in the program.

Shulman says that currently, Emory uses about 20 percent problem-based learning and 80 percent lecturing.

"I think it's a terrific system, but I also can see a lot of problems with it," Shulman says. "When I started I was hoping we'd move towards 100 percent-now I think it has to be a mixture."

He is concerned that students may not receive as much information through the different curriculum as they would with a more traditional lecture format.

"Some students are nervous that they aren't getting enough material," Shulman says. "You have to rely a lot more on your classmates."

Financial concerns-small group courses require more faculty than a lecture-based curriculum-also hamper some schools from following HMS.

Federman says that HMS is "lucky in having such a large faculty and an extraordinary commitment to teaching."

Also, according to Schulman, students are used to traditional learning methods and may not take to change so easily. For this reason among others, he says Emory is not ready to make the switch yet.

"We feel pretty good about the graduates we turn out," Schulman says. "For us to make changes, we want to make sure that the changes will have substantial value."

"The real test will come a long time down the road when we see which group of students does better," he says.

But Federman says that it is difficult to measure results in graduates.

"To prove that the New Pathway has accomplished something specific is hard," Federman says. "Medical students will adapt to anything in order to get their education. But they like [the New Pathway] better."

Good explains that today most medical schools have adopted at least part of the system. Almost all schools have behavioral science teaching like the patient/doctor course at HMS.

But schools continue to look into new methods. The Robert Wood Johnson Foundation funded a project allowing eight medical schools to develop new curricula.

While the rest of America's medical schools tinker with similar programs, HMS says it plans to stay with this innovation for the foreseeable future.

"Lots and lots of schools have followed Harvard partly, but most have not gone as far," Good says. "There's a more creative streak to learning medicine at Harvard."