Monday, May 08, 2006

Who needs all that basic science bunk?

I enjoy reading Chris Rangel’s blog. He offers entertaining and incisive commentary on things I’m interested in though I sometimes disagree with him. Today he pushed one of my buttons with Do doctors really need to know anatomy and that other basic science stuff? He cites an article expressing concern about medical school curricula in Australia which have cut back on basic sciences. Now apparently some senior students don’t know the heart from the liver, or the location of the prostrate gland. Critics say they’ve filled courses with so much fluff that there isn’t room for adequate basic science education. Rangel acknowledges both sides of the debate but questions the importance of basic science and concludes “In the future your primary care provider may have no idea what frame-shift genetic encoding is and you won't care less as long as you get something to help you sleep.” (Maybe I misread Dr. Rangel, but this seems a surprising statement from one who invokes the basic science argument so passionately in defense of the teaching of evolution. But I digress).

Why is basic science important in medical education? Let’s first define levels of basic science that may or may not be important. It’s probably a waste for most of us to memorize the chemical structure of amino acids, but it may be important to know enough about their structure and properties to understand that some are hydrophobic and can traverse membrane lipid bilayers while others are hydrophilic and form hydrogen bonds, the basis for the secondary structure of proteins. Memorizing all the steps in the glycolytic sequence and the Krebs cycle won’t make you a better doctor but it could be important to understand how those reactions yield energy, why a molecule of glucose yields only a couple of ATPs in the glycolytic sequence, but an additional 30 some odd in the Krebs cycle, a fact that explains the difference between aerobic and anaerobic metabolism and why folks have to breathe. It’s all about the how and why of health and disease.

Doctors, whether in private practice or the towers of academe, are sometimes called on to teach (the word doctor means teacher) and to comment on public issues relating to the health sciences. On a given occasion a conversation may turn to anti-oxidants, stem cells or cloning. As a doctor one is expected to inform such conversations in a meaningful way. That requires more than a superficial understanding of the scientific underpinnings of the topic. Unfortunately, most people merely spout hot air about such things, only showing their ignorance. (Tom Cruise might have avoided considerable embarrassment had he known a little biochemistry).

Knowledge of the basics is also helpful in distinguishing between science and pseudoscience. Consider this page promoting wheatgrass from the Creighton University Alternative Medicine links. (Authorship of this page is not specified, but the main page of the alt med links suggests that the articles were written by Creighton med students and faculty. Some alt med articles are appropriately critical. Although others seem uncritical or even promotional, all contain a disclaimer that neither the university nor the med school endorses the methods). A big dose of biochemistry and physiology might help here. In “explaining” the health effects of wheatgrass the article notes that the plant contains enzymes which “aid the body in digesting foods, building protein in the bones and skin, and in detoxification processes.” Did the author not know that enzymes cannot be absorbed into the body intact? How then are they to participate in bone building or detoxification? (What is the biochemical process of detoxification, exactly?). Also among the “scientific benefits” touted for wheatgrass is its content of chlorophyll, claimed to protect against carcinogens and dissolve kidney stones. Never mind the fact that chlorophyll has no known function in human metabolism. Then there’s this page on the “mechanisms” of Reiki---speaks for itself. Some medical schools in the U.S. are skimping on teaching basic science. I hope these pages don’t reflect the quality of basic science education at Creighton.

Why is knowledge of basic science important in the day to day practice of medicine? First, basic science understanding provides a conceptual framework in which to incorporate new facts. Lacking such a framework one must assimilate facts by sheer memorization, a much less effective way to learn. When memory fails one can look things up, much easier nowadays. That may not work in an emergency situation or when the patient forgets to read the textbook. Over many years of practice (more years than I care to admit) I’ve seen errors in the care of complex patients, despite adherence to guidelines, all because of a lack of appreciation for basic principles of biochemistry and physiology.

Dr. Rangel writes “Physicians traditionally get a liberal education because we have this sense that we should create a well-rounded doc as physician-scientist. In decades past it was believed that physicians should not only be practitioners but investigators on the forefront of a mysterious new field. However, these days physicians are more often seen as ‘providers’ who toil away following practice guidelines. The attitude these days seems to be ‘leave the science to the scientists. Let them find new diseases and develop new treatments.’" That’s an accurate depiction of the prevailing attitude. I don’t like that mindset and don’t want to be relegated to the status of “provider”. I trust Dr. Rangel doesn’t either.


Anonymous said...

Uhh . . . why should what you WANT matter? If technician doctors mindlessly followly guidelines provide as good as care as doctors who know every step in the Krebs cycle, isn't the former BETTER? First, more people could become doctors, lowering the cost of medical care. Second, medical education could be cheaper--a good thing given that med schools are publically subsidized.

R. W. Donnell said...

To anonymous,
I think you are misrepresenting my position. Go back and read my statement about the Krebs cycle. Doctors don't need to know every step in the Krebs cycle. However,doctors who not only practice according to the evidence but also *understand* how the body functions in health and disease will, other things being equal, make fewer mistakes, and give better care than any provider who mindlessly follows the book.

Anonymous said...

various guidelines are changed, discarded and introduced on annual basis. what is dogma today is outdated in 5 years. Unless practitioners have some understanding of the basic and statistical science behind guidelines, they will likely misapply and misuse guidelines.

Med school applications are at historic lows, anyone with a B average can enter...which may be wny the alternative medicine psuedoscience finds its ways into modern medicine.

it is possible that a large increase in physicians could lower costs, but it is just as possible that costs will go up. One example is in the legal community. Lawyers outnumber physcians by 5:1 and it seems that we are drowning in excess costly litigation. A large increase in physicians might lead to increased pressure to generate work to bring home income. As it is now, most physicians are so busy that they try to avoid unneeded tests and therapies. The more we do, the more swamped we are. So I am not convinced by training huge numbers of physicians will lower costs.