Wednesday, January 30, 2008

Too much basic science?

DB of Med Rants has written a series of interesting posts on how to reform the premed curriculum and hints at changes in the medical basic science courses. He has made general recommendations rather than a detailed description of course content. Although I would likely agree with many of the changes he has in mind and certainly respect his extensive expertise and experience as a medical educator I have a few concerns.

His proposals would streamline the basic science portion of the curriculum and encourage a well rounded education in the humanities. He and some of his commenters bemoan the “hard core” basic science courses (organic chemistry is frequently cited) which do not seem, in any direct way, to make one a better doctor. The same could be said, of course, for the humanities. Both content areas are important parts of a solid background for the practice of medicine but neither helps a doctor decide which antibiotic to give or what type of IV fluids to run. Both are important, but in less direct and tangible ways.

My concerns are two fold. First, with basic sciences already being de-emphasized we may be going down a slippery slope. As an example of where this type of thinking may lead consider an article in BMJ from several years ago with these suggestions for the medical school of the future:

From day one the focus of the course will be on "whole patient medicine," which is to be based on holistic consultations with patients in their real contexts. There will be no preclinical-clinical divide, and gone will be the days of freestanding courses in biochemistry, physiology, and anatomy.

A number of schools, apparently, have already adopted this model to one degree or another with problem based learning and other means of integrating the basic science and the clinical portions of the curriculum. This style of learning could be effective. However, the BMJ piece goes on with suggestions which raise concerns that the basic sciences would be slighted:

There will be no exams in anatomy, physiology, or biochemistry, and no one will need to learn by rote the entire Krebs cycle or the names of all those little holes in the skull. All students will have to demonstrate the critical appraisal skills of evidence based practice.

No exams in anatomy, physiology or biochem? I’m sure this isn’t the type of curriculum change DB has in mind but it seems to be the direction things are heading.

More from the BMJ article:

The modular nature of the course will provide a common pathway to careers across the whole spectrum of the health profession from medicine and nursing to management and health promotion. Having learnt together as students in a range of disciplines, our graduates will be well equipped to learn both with and from each other and to continue lifelong interprofessional learning.

The article notes that physicians and allied health professionals would have a “common course with different exit points” implying that physicians would need to be no better trained in basic sciences than would allied health professionals.

My second concern is that medical schools may already have gone too far in reducing basic science teaching as evidenced by observations of medical students which Orac summarized nicely in a post from a couple of years ago. Given the utter credulity of many of today’s medical students toward quackery one has to wonder whether they’re learning any chemistry or physics at all. If students had even a modicum of understanding of these sciences would we be seeing promotions like this or this? Of course I could trot out many, many more examples.

I will continue to follow this debate and look forward to additional posts from DB on the subject.


rlbates said...

Nice post. Hope someone will notice. I think the basic sciences are great building blocks for the rest of our education.

Anonymous said...

I'm with you. A thorough grounding in basic science education both pre-med and in the first two years of medical school is what separates the physician from the physician-extender. Sure, it's difficult. I may not remember a lot of neuroanatomy, but it comes back quickly with a brief review if I need it. Take away the science, and pseudoscience takes over. We had an intro to physical diagnosis in the first year at my medical school 35 years ago. I would have liked more education in statistics, but I think the traditional post-Flexner model has worked well. Let's not turn back the clock to the snake oil days.

db said...

Please comment on my proposed 1st year curriculum

blacktag said...

The best education for the sceptical doctor is a course of philosophy, with a good dose of statistics and epidemiology.

Some basic science is helpful, but rote memorization of the Krebs cycle is frankly unhelpful. Rather, broad principles such as evolutionary biology are probably more interesting and relevant.