The curriculum of the Duke University School of Medicine is unique and innovative because it starts clinical clerkships in the 2nd year and has introduced research fellowships in the 3rd year. New external pressures require innovations. The innovations of the Duke curriculum are as follows: greater integration of clinical and basic-science education, continuous early clinical exposure in clinics and hospitals, a stronger structure for clinical educational programs, monitoring of each student's performance and of the effectiveness of programs, and extensive program evaluation by surveying directors of graduates.