Tuesday, October 27, 2009

The Basic Science Medical Education Dilemma

This is a guest post by John Wetzel from Wiki PreMed

For medical education, the question is not only what to teach and what to leave out but also how to teach it. Alfred North Whitehead in his famous essay 'Science in the Modern World' described a situation in which the explosion of knowledge in modernity made the 'Renaissance Man' no longer possible, and that to be effective, a modern person had to content themselves with being a specialist, and this was in the 1920's! I think this predicament of modernity creates a real tension for medical education, especially, because the human body is a microcosm of the universe, of the whole of science, not only in the sense of complexity but in the sense that a person's health is bound to it, so it is very difficult for any person studying medicine to leave off something potentially important just because the mind has limited capabilities. Furthermore, there is a tradition which makes it hard for any teaching generation to make things easier for today's students than they had it themselves in their own education. However, the rate of increase of the knowledge base means that even if the discipline doesn't change, the disposition towards the knowledge among educators has to change. Medical students can't learn everything. In biochemistry alone, medical students are asked to retain an incredible amount of information regarding mechanism after mechanism, but this was true even fifty years ago. However, in the intervening years, students have been given a new encyclopedia to learn in the field of molecular biology. With gene expression alone, there are now elaborate signaling pathways and mechanisms like alternative splicing and RNA interference which have been elucidated only in the past ten years. So there needs to be a lot of debate about what to teach and what not to teach.

Of course one important standard is whether a piece of information is relevant to clinical judgment. Something as fundamental as the Krebs cycle is likely only important in clinical practice for a subset of metabolic disorders. Within every clinical specialty there are fundamental principles from basic science which are important for understanding of symptoms and treatment on a daily basis, but not for other specialists. Bernoulli's Principle and Poisseuille's Law for the cardiologist. Solution and acid-base equilibria for the nephrologist. Hooke's Law for the orthopedist. An infectious disease specialist is not going to think about these things very often I suppose. In fact, the specialists themselves probably don't think about them too much on a daily basis, except in difficult cases, but the knowledge must be there in the first place for the specialist's education to have been coherent when they received it. This is where I have an issue with the complaints of many medical students that much of the science they learn is irrelevant information. Students complain about learning every structure in the Krebs cycle, but this is the wheel at the center of the living system. To understand energy flow in metabolism makes a great deal else coherent, although I have big problems with how the Krebs cycle and a lot of biochemistry is taught. In my opinion, if instructors felt they could use the field of reference of physics and general chemistry in a sophisticated way to animate the presentation of the Krebs cycle, it would mean a lot more to students.

If you read discussions among medical educators, you see a lot of advocacy for more emphasis on clinical experience and communication at the expense of basic science. Medical educators may be giving up on making medical school an experiment in finding the maximum possible amount of information a human mind can hold, which is probably a good thing. It may be that there is cost benefit to teaching doctors to be better communicators because it leads to better outcomes for patients without too much trouble. Convincing people to quit smoking has done more against cancer than understanding the mechanism of histone acetyl transferase, at least so far.

The proposition that animates my own work is that a more effective curriculum at the earlier stage would prepare entering students significantly better for the challenges of understanding and retention they face in medical school, by which I mean the education they receive at the fundamental level of physics, chemistry, organic chemistry and biology. Medical school would be more vivid if students learned the fundamental physical and biological sciences within a combined curriculum that builds on itself, not within disconnected modular courses. How can a person understand free energy change in chemistry without mechanics, electrodynamics, and thermodynamics from physics? How can you understand oxidative metabolism without oxidation reduction? Being a person who has worked very closely with many small groups of premedical students, taking them through the basic sciences in review more times than I want to admit, I'm burdened with knowing how little conceptual fluency entering medical students actually possess after their undergraduate years that would help them unify the enormous encyclopedia already in their heads, let alone what is coming in medical school.

So I made the WikiPremed MCAT Course because I hoped it would benefit people. It’s just a small part of the whole movement to make education more accessible online. I also hoped it would be a way to share some ideas about designing the basic science curriculum to be more appropriate for future doctors at the undergraduate level. The sequence of topics and goals in the course represents my best effort at what a unified, interdisciplinary, spiraling curriculum for basic science would look like (without lab component). I think medical school would be more interesting and enjoyable if students were prepared by a science program that followed a sequence like this one, where chemistry comes out of physics and the biological sciences out of the physical sciences. If anyone is interested, they can go visit, at least to see what a person is capable of who gets so deep into a project they can only double down. I'm probably too close to the work to see it's problems clearly, so I am very interested in substantive criticism, although any encouragement is also welcome.

To learn more about John's project, visit WikiPreMed at http://www.wikipremed.com

Have your own views to share? Submit a guest post at scrubnotes at gmail dot com today

1 comment:

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