STANFORD, Calif. Dora Castaneda has wanted to become a neuroscientist since her sophomore year of college, when she volunteered as a physical therapist to a 4-year-old autistic boy.
So when Stanford announced last month it would become the first U.S. university to require new medical students to pick ''scholarly concentrations'' similar in spirit to undergraduate majors Castaneda didn't hesitate. The author of an upcoming epilepsy article in the Journal of Neurosci-ence, she selected the molecular and genetic medicine track, then began another research project on stroke.
''Neurological brain disorders, how they function, why they happen this is what I want to do with my career,'' Castaneda said.
Attracting specialized, career-focused students is one reason Stanford University Medical Center overhauled its curriculum and required students to pick a concentration by the end of their first year. Officials say the policy puts Stanford at the forefront of medical education.
Harvard Medical School is considering a similar requirement, said Malcolm Cox, Harvard's dean for medical education. Many of the nation's top medical schools, including Michigan and Northwestern, are introducing dual-degree programs aimed at providing students with subspecialties long before their hospital residencies.
But critics, including some Stanford medical students, say the requirement piles even more pressure on harried first-year students. Others say the specialized approach does little to encourage general practitioners and could exacerbate a growing shortage of American primary care physicians.
School officials argue that eight broad concentrations including immunology, women's health, bioinformatics and bioethics accommodate family medicine or any niche. Administrators say the extra focus simply provides a channel for students' intellectual passion.
''Students in medical school turn into cookie cutters, all learning the same, huge amount of data, and by the end the idealists are gone,'' said Dr. Julie Parsonnet, Stanford's senior associate dean for medical education. ''We're saying, 'We know you're all different from each other and you have individual reasons for going to school.' We want to foster that passion and still produce great doctors.''
Stanford's program came after an 18-month curriculum review, when officials discovered 70 percent of students were taking five or more years to get through the four-year program. Most spent an extra year on independent projects.
When asked what they'd want in a retooled program, Stanford students overwhelmingly asked for more time for unique research in part to pad their resumes and land the specialized residencies seen as a launching pad to lucrative careers.
The average medical student in 2002 graduated with $104,000 in student debt, according to the Association of American Medical Colleges. The salary gap between general practitioners and neurosurgeons or other highly specialized doctors is often several hundred thousand dollars per year.
Stanford's newest class of 87 students must devote at least 200 hours to a project in their concentration. Officials added three weeks to the fall quarter and asked professors to spend less time in the classroom each week and more time supervising students in interactions with patients.
Administrators will update concentrations to reflect demands of hospitals and research labs; they may add concentrations such as bioterrorism, depending on geopolitical trends. Five more areas, including international health, infectious disease and cardiovascular medicine, will debut next year.
Educators are monitoring Stanford, and success could inspire programs throughout the country. Proponents say the ''Stanford model'' reflects the competitive nature of medical students.
''Sometimes I think we have students whose interest in radiology began in kindergarten,'' said Dr. Greg Vercellotti, senior associate dean for education at the University of Minnesota Medical School. ''These are very career-minded people.''
Although Vercellotti has no immediate plans to introduce a concentration requirement, the Minneapolis-based school has seen tremendous growth in the number of medical school applicants to joint-degree programs. More medial students are graduating with degrees in informatics, law and business administration.
Dr. Raymond Curry, executive associate dean for education at Northwestern University's Feinberg School of Medicine in Chicago, called Stanford's experiment provocative and risky. Physicians in training must learn a staggering array of facts required by the Liaison Committee on Medical Education, North America's accrediting authority for medical schools. It's unclear whether Stanford's program could prove distracting for first-year students.
''The classic metaphor for medical students is that they're trying to drink from a fire hydrant there's so much information,'' Curry said. ''The trick is whether Stanford will manage this tension between medicine as an all-encompassing liberal education endeavor, and the fact that we have to ensure that every student has been introduced to a very broad range of topics we're required to present to them.''
First-year Stanford medical student Ryan Williams is considering health services and policy research or public service and community medicine concentrations, but the would-be child psychiatrist feels overwhelmed.
''Ultimately, I think it puts us in a better career position,'' Williams said of the curriculum change. ''But just getting through registration, orientation, figuring out financial aid and finding the grocery store those are bigger immediate concerns.''
Joan Werblun, volunteer executive director for Citizens for the Right to Know, said Stanford's experiment, if widely copied, could encourage specialization when managed health care increasingly ''shuttles people to the general practitioner.''
''I don't know if this is going to work,'' said Werblun, a former nurse who heads the Sacramento-based patient advocacy group. ''Managed care could turn around and bite Stanford.''
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