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Stanford Report, February 20, 2002

Paul Berg explores change: Dinner remarks from the medical school retreat, Feb. 7-8, 2002

Our mission this weekend is to examine the present state of the Stanford Medical School, to plan for how it could be advanced, and to map a strategy that will allow us to go forward with a successful fundraising campaign. In that context I want to comment on the relatively conservative but widely held aphorism "If it ain't broke don't fix it" as opposed to a more activist stance that posits, "CHANGE IS GOOD." Of course, the former view supposes that a good and agreed upon objective metric exists for determining whether or not things are "broke" and how much or how little fixing is needed. Undoubtedly, changes produced by incremental fixes are easiest to achieve. However, they are rarely transforming or disruptive and the system adjusts without noticeably changing the institution. Aside from possibly blurring the vision that gave the enterprise birth, that solution precludes "thinking outside the box."

But even if we assume that our enterprise is not broken, there is ample reason and more importantly considerable heuristic value to exploring whether totally different solutions would be an improvement and perhaps even much better.

Indeed, the very exercise of exploring change challenges prevailing assumptions in new ways, encourages the imagination to roam freely over possibilities that might otherwise not be considered, and energizes the search for new solutions. In a setting where innovation is prized and the constraints are largely of our own making there is little reason not to explore a full range of possibilities.

Once before, Stanford School of Medicine was faced with an opportunity to rethink its mission and ways to achieve the goals it set. That challenge was thrust upon it almost 50 years ago when the Stanford Board of Trustees decided to move the medical school and its associated hospital to Palo Alto. The board acknowledged that the medical school, located in San Francisco since its founding in the mid-19th century, was inadequate to meet the challenges of the future. There were both academic and economic reasons driving the decision to relocate. First, demographic analyses made it clear that the mid-peninsula's population and industrial development were exploding and could provide more than ample numbers of patients for the school's clinical needs. Second, the pre-clinical sciences, anatomy, physiology, medical bacteriology and biochemistry (which at the time was taught in the chemistry department) were taught on the university campus while pharmacology, pathology and all the clinical work was carried out at the Stanford hospital in San Francisco. Aside from the logistical nightmare of moving and communicating between the two sites, and the deficiencies of teaching basic sciences and clinical medicine separate from each other, there was the lack of opportunity to interact with rich complementary activities in the university.

Looking back today, it's difficult to overestimate the boldness of the Trustees' decision because implementing it would incur considerable expense and, therefore, necessitate raising considerable funds to make it a reality.

But equally challenging was managing the substantial resistance to moving from "old-timers" in the clinical faculty. The necessity to relocate geographically and the specter of being uprooted from their lucrative private practices in the hospital were sufficient to cause many to give up their academic appointments and remain behind. That was a defining moment for the school as it established a new ethos for the clinical faculty; they were expected to conduct scholarly research in addition to their clinical responsibilities.

The Trustees' decision in July of 1953 set in motion a planning exercise that was as challenging then as ours is now. One component was the planning for and construction of a new medical center. That task was entrusted to a group of faculty who selected Edward Durrell Stone, a noted architect of monumental buildings, but with no experience in designing and building a medical center. That chapter in the life of the medical center is another story, ample grist for those who condemn or admire its design But perhaps the most critical challenge was to create a curriculum that would reflect the faculty's commitment to scholarly medicine and train medical students who could legitimately claim to be physician- scholars. The principles and realities that guided the planning process and the final solution were novel in their time and I quote from the original planning documents:

1. "The growth of medical science is so great and continues at so rapid a pace that its comprehensive coverage cannot be achieved" and therefore, only " a core of knowledge should be presented to all students irrespective of their eventual choice of medical career".

2. Each student, as an individual, and in accordance with their particular needs and abilities, should supplement a study of the core through independent study of various kinds and through elective work".

Complementary to these notions, the planners emphasized that "the student of medicine has passed beyond that stage of their education where the mere acquisition of ‘facts' can be defended. "They are essentially graduate students and should be encouraged to learn in terms of attitude toward and approach to problems in medicine, rather than in terms of the acquisition of techniques or the accumulation of data at the expense of interpretation. Students should understand the scientific method, since only through its practice can the problems in medicine be susceptible of solution".

To implement these ideals, the architects for the "Stanford Plan" designed a 5-year curriculum into which students entered after three or four years of college. Contrary to the practice of any other medical school, an amount of time equivalent to one year was set aside as "free time" or as it was called "university time" spread over the first three years of the program. That was managed by having classes (the "core") scheduled during only about 60% of the day. Even during the last two years of clerkships, substantial blocks of time, nearly a third of the last two years, were set aside as free time. The so-called free- or university time was intended for student's to work in any department of the University including the possibility of completing a B.S. or M.S. degree in areas of their choice. In practice, a very high proportion of the 64 students in each entering class chose either to do research in one or another of the basic or clinical sciences, or in related areas of the social sciences during that set-aside. After completing their clinical clerkships, some continued the research they had begun earlier, but some chose to pursue specialized projects or clinical training at other medical centers elsewhere in the U.S. or abroad.

Predictions that Stanford School of Medicine's five-year requirement would price itself out of the market were unfounded as the first and subsequent entering classes were greatly oversubscribed. Those that were admitted came because of the opportunities provided by the novel curriculum and the implied emphasis on medical science.

The students' and faculty's excitement of being part of a dedicated research and scholarly environment was plainly evident and the Stanford Plan's reputation spread widely.

Funding for the experiment from foundations and private philanthropy was not hard to raise. It was also a special source of pride to the faculty that Stanford's medical students ranked number 1 in every one of the six pre-clinical sciences tested, with nearly half being awarded honors. The placement of graduates for additional clinical training or post-doctoral research was similarly successful.

In time, external economic and social pressures took their toll on the unique character of the medical school's curriculum and culture. During the late 1960's, the medical student curriculum was modified to provide even greater flexibility in the options for study-work experience but that experience was never successfully implemented. Over the last 20 years, the impact of reduced reimbursement practices has placed a too high a premium on clinical earnings thereby diminishing the intensity of the faculty's clinical research programs.

But in tooling up for a major capital campaign, we have a fresh opportunity to set a new course, one that would enable us to fulfill our potential for innovation and leadership. I believe that we should set a bold agenda, one that embraces the excitement of a grander vision. I can imagine a School of Medicine that identifies disease-based discovery and translation of that discovery into improved health care as its most important mission. To achieve that goal we should aspire to a community in which scientists, physician-scientists and scholars, and certainly students are focused on this task as its highest priority. As Stanford gains unequaled prominence in its ability to deliver on the promise of biomedical science, it will provide the driving force for energizing and sustaining the philanthropic efforts needed to make it a reality.